Mechanical Support in Critical Coronary Syndromes: Early Ventricular Assist Devices for LMCA Occlusion with Cardiogenic Shock

Abstract

Acute occlusion of the Left main coronary artery (LMCA) is a rare but very serious angiographic finding with short-term life-threatening consequences. The clinical presentation is severe, with a high incidence of cardiogenic shock and sudden death. Treatment must be rapid and organized, and requires an angioplasty combined with hemodynamic support and the usual resuscitation resources. We report the case of a 62-year-old patient admitted to our center after a resuscitated cardiac arrest, the post-resuscitation EKG revealed an ST segment elevation. The patient was rushed to the angiography room and we objectified a complete occlusion of the LMCA. Provisional stenting with mesh opening towards the circumflex with a good result, with rapid restoration of a TIMI III flow. The persistence of shock with metabolic acidosis despite improvement in BP led to the use of hemodynamic support : Veno-Arterial extracorporeal membrane oxygenation (VA-ECMO) was rapidly initiated for circulatory support. The patient stabilized under ECMO support and was gradually weaned off mechanical circulatory assistance. He made a full neurological recovery and was discharged home in stable condition. This case highlights the importance of rapid recognition and a multidisciplinary approach, combining emergent PCI with mechanical circulatory support, in the management of catastrophic LMCA occlusion. The timely use of VA-ECMO can be life-saving by providing hemodynamic support and allowing successful revascularization in otherwise fatal presentations.