Document Detail


Preoperative optimization of multi-organ failure following acute myocardial infarction and ischemic mitral regurgitation by placement of a transthoracic intra-aortic balloon pump.
MedLine Citation:
PMID:  20961840     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: The management of acute myocardial infarction with resultant acute ischemic mitral regurgitation and acute multi-organ failure can prove to be a very challenging scenario. The presence of concomitant vascular disease can only serve to further compromise the complexity of the situation. We demonstrate a new indication for the transthoracic intra-aortic balloon pump as a preoperative means of unloading the heart and improving clinical outcome in such high-risk patients with severe vascular disease.
METHODS: We present the case of a 75-year-old man with a history of severe vascular disease who was transferred emergently to Vanderbilt University Medical Center with an acute inferolateral wall myocardial infarction resulting in severe acute ischemic mitral regurgitation and acute multi-organ failure. He presented with shock liver (serum glutamic-oxaloacetic transaminase [SGOT] of 958), renal failure (creatinine of 3.0), and respiratory failure with a pH of 7.18. Emergent cardiac catheterization revealed 100% occlusion of the left circumflex artery as well as severe ileofemoral disease. The advanced nature of his ileofemoral disease was such that the arterial access catheter occluded the right femoral artery. The duration of time that the catheter was in the artery led to transient limb ischemia with an elevation of his creatine phosphokinase (CPK) to 10,809. Balloon angioplasty followed by stent placement was successfully performed, which restored flow to the coronary vessel. Given the grave nature of the patient's condition, we were very concerned that immediate operative intervention for his condition would entail prohibitively high risk. In fact, the Society of Thoracic Surgeons predicted risk adjusted mortality was calculated to be 56%. In order to minimize patient mortality and morbidity, it was critical to help restore perfusion and organ recovery. Therefore, we decided that the chances for this patient's survival would improve if his condition could be optimized by placement of an intra-aortic balloon pump before undergoing surgery. Given the limb ischemia following arterial sheath insertion, femoral placement of an intra-aortic balloon pump was not an option. Placement of the intra-aortic balloon pump was attempted via a left subclavian artery cutdown, but was not successful. Therefore, a sternotomy was performed, and we placed a transthoracic intra-aortic balloon pump in order to stabilize the patient's hemodynamics and allow for organ recovery.
RESULTS: The patient showed immediate improvement, and 4 days later, the multi-organ failure resolved and he successfully underwent mitral valve replacement. The patient was ultimately discharged to a local rehabilitation facility in satisfactory condition.
CONCLUSION: This case demonstrates the utility of a transthoracic intra-aortic balloon pump as a preoperative means of stabilization in very high risk patients with severe peripheral vascular disease in whom the conventional approaches are not possible.
Authors:
Ramanan Umakanthan; Robert Dubose; John G Byrne; Rashid M Ahmad
Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  The heart surgery forum     Volume:  13     ISSN:  1522-6662     ISO Abbreviation:  Heart Surg Forum     Publication Date:  2010 Oct 
Date Detail:
Created Date:  2010-10-21     Completed Date:  2011-04-07     Revised Date:  2011-08-05    
Medline Journal Info:
Nlm Unique ID:  100891112     Medline TA:  Heart Surg Forum     Country:  United States    
Other Details:
Languages:  eng     Pagination:  E342-4     Citation Subset:  IM    
Affiliation:
Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, 2311 Pierce Ave., Nashville, TN 37232, USA.
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MeSH Terms
Descriptor/Qualifier:
Acute Disease
Aged
Coronary Angiography
Follow-Up Studies
Heart Catheterization
Heart Valve Prosthesis Implantation
Humans
Intra-Aortic Balloon Pumping / instrumentation*
Male
Mitral Valve Insufficiency / complications*,  diagnosis,  surgery
Multiple Organ Failure / etiology,  surgery*
Myocardial Infarction / complications*,  diagnosis,  surgery
Myocardial Revascularization
Preoperative Care / methods*

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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