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In dire circumstances, which comes first: hemodynamic support or PCI?
A female patient presenting with STEMI and cardiogenic shock was referred for primary PCI. She was in extremis: bradycardic and hypotensive with systolic BP below 50 mm Hg despite inotropes. A transvenous pacemaker was inserted for chronotropic support. The guide catheter and other interventional supplies were opened in preparation for PCI. Hemodynamic support was subsequently inserted but only after the patient arrested and required CPR.
In situations like these, an important decision needs to be made by the operator: Should a hemodynamic support device, such as extracorporeal membrane oxygenation, TandemHeart (CardiacAssist) or Impella (Abiomed), be inserted, or should PCI be promptly performed to restore coronary perfusion?
Michael S. Lee
Ideally, I would like to reference the current literature (preferably a large clinical trial), but it would be nearly impossible to conduct a clinical trial in patients who present with this clinical scenario. Based on my personal experience, I would favor first establishing circulatory stability with a hemodynamic support device before the patient could arrest for the following reasons:
- Once the patient has lost spontaneous circulation, mayhem ensues in the cath lab, with people running in to help with the code. However, if a hemodynamic support device is inserted prior to PCI, the patient will still have circulatory support even if the patient arrests.
- Once the patient experiences cardiac arrest, which requires CPR, a tailspin begins, with metabolic derangement, including metabolic acidosis and massive release of proinflammatory cytokines, which have deleterious systemic effects.
- Once the device is inserted, it is much easier to perform PCI with a decent BP rather than systolic BPs in the 50s or less. The operator can proceed with PCI deliberately in a more controlled setting with the assistance of hemodynamic support to avoid the possibility of having to stop in the middle of the PCI for CPR.
Furthermore, it is highly unlikely that opening the infarct-related artery first will immediately reverse cardiogenic shock. Rather, in my experience, reperfusion by either crossing the lesion with a guidewire or balloon dilatation often results in electrical instability like ventricular tachycardia/fibrillation, further exacerbating the situation.
Rather than losing valuable time trying to reperfuse the infarct-related artery, my preference is to preemptively insert a hemodynamic support device expeditiously as opposed to hurried insertion during full cardiac arrest.
In the absence of trial data, we must rely on experience. Since our cumulative experience is more robust than our individual experience alone, I ask you to share your preferences.