From Collapse to Recovery: Managing a Complex Case of Acute Coronary Syndrome with Cardiogenic Shock

From Collapse to Recovery: Managing a Complex Case of Acute Coronary Syndrome with Cardiogenic Shock Blog

From Collapse to Recovery: Managing a Complex Case of Acute Coronary Syndrome with Cardiogenic Shock

When it comes to cardiac emergencies, few situations test the limits of modern medicine like cardiogenic shock. It’s a race against time, where survival hinges on immediate, precise, and multi-disciplinary care. In this blog, we explore a complex real-world case of a 65-year-old male with multiple comorbidities, who faced a life-threatening episode of acute coronary syndrome (ACS) complicated by anterior wall myocardial infarction (AWMI) and cardiogenic shock.

Thanks to cutting-edge interventions—including intra-vascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) and Impella support—this high-risk patient was stabilized and successfully treated. Let’s walk through the medical narrative and understand the intricacies involved in saving this patient’s life.

 

A Patient With a Heavy Clinical Past

The patient, a 65-year-old male, had been managing several chronic conditions:

  • Hypertension (HTN)

  • Type 2 Diabetes Mellitus (T2DM)

  • Rheumatoid Arthritis

  • Coronary Artery Disease (CAD), status post-PTCA to the left main (LM) and left anterior descending artery (LAD) in April 2010

His follow-up coronary angiograms (CAG) in October 2010 and May 2011 showed good results with a patent stent and no restenosis. Despite a stable cardiac history for over a decade, his comorbidities placed him at high risk for recurrent cardiac events.

A Life-Threatening Presentation

Fast forward to the present admission—he presented with:

  • ACS (Acute Coronary Syndrome)

  • AWMI (Anterior Wall Myocardial Infarction)

  • Severe left ventricular dysfunction (LVD)

  • Cardiogenic shock

  • Multi-organ dysfunction syndrome (MODS) including:

    • Congestive Hepatitis

    • Non-oliguric Acute Kidney Injury (AKI) on Continuous Renal Replacement Therapy (CRRT)

This was a classic case of the “perfect storm” in cardiology: the heart’s ability to pump was compromised, leading to poor perfusion of vital organs. Immediate intervention was critical.

Initial Stabilization and VT Episode

Before arriving at the current tertiary care center, the patient was thrombolysed using Reteplase, a fibrinolytic agent used in STEMI cases. However, the impact was limited due to the severity of his coronary pathology and underlying comorbidities.

To add to the complexity, he developed ventricular tachycardia (VT)—a dangerous arrhythmia that could have been fatal if not addressed swiftly. He was successfully reverted with 150J DC shock, a testament to timely critical care intervention.

The Turning Point: Diagnostic Angiogram

With the patient now stabilized from a rhythm perspective and on full organ support, a diagnostic coronary angiogram (CAG) was performed.

Findings included:

  • Left Main (LM) artery: Significant in-stent restenosis (ISR)

  • Double Vessel Disease (DVD): Disease involving both LAD and another major coronary artery

The ISR of the previously placed LM-LAD stent was the culprit behind the acute event. ISR is a serious complication where scar tissue or new plaque builds up inside a stent, causing it to narrow again.

High-Stakes Treatment: IVUS-Guided PTCA with Impella Support

Given the complexity, IVUS (Intravascular Ultrasound) was employed. IVUS provides real-time imaging from within the coronary arteries, giving a 360-degree view to precisely assess plaque burden, vessel size, and stent placement.

Key Interventions Done:

  • One drug-eluting stent (DES) placed from mid to distal LAD

  • Two drug-eluting balloons (DEBs) used for LM to LAD segment, addressing restenosis without placing another stent in the already treated LM area

  • Impella device support—a percutaneous mechanical circulatory support device used to maintain cardiac output during high-risk PCI

This strategic mix allowed revascularization while minimizing further trauma to the LM segment, reducing the risk of complications.

Impella: A Game-Changer in Cardiogenic Shock

The Impella device, a small pump inserted via the femoral artery, temporarily takes over part of the heart’s function. It unloads the left ventricle, reducing myocardial oxygen demand and increasing perfusion to organs—a critical factor for patients with severe LVD and MODS.

In this case, it gave the heart a much-needed rest during the intervention and allowed the team to perform a meticulous PCI without the added burden of unstable hemodynamics.

Post-Procedure Outcome

The intervention was a success:

  • The patient remained stable on Impella support post-PTCA

  • Gradual weaning from CRRT as renal parameters improved

  • LFTs began normalizing, showing signs of liver recovery

  • Left ventricular function remained severely impaired, but hemodynamic status stabilized

The patient was managed in the coronary care unit with close monitoring, optimization of heart failure therapy, and tailored post-PCI care.

What Makes This Case Unique?

  1. Layered Comorbidities: T2DM, HTN, rheumatoid arthritis—all contributing to systemic inflammation and accelerated atherosclerosis.

  2. ISR in LM stent: High-risk territory requiring delicate handling.

  3. MODS: Hepatic and renal dysfunction added procedural risk.

  4. Use of Impella: Enabled safe revascularization in cardiogenic shock.

  5. Combination Strategy: Stent for LAD, DEBs for LM-LAD—smart, lesion-specific approach.

  6. IVUS Guidance: Ensured precision in sizing and positioning.

Lessons for Clinical Practice

  • IVUS should be considered mandatory in left main interventions or ISR cases to avoid stent under-expansion.

  • Early mechanical support like Impella can change the trajectory in shock patients.

  • DEB technology has a growing role in ISR management, avoiding multiple metal layers in vital segments.

  • Multidisciplinary care, including cardiology, nephrology, and critical care, is vital in MODS scenarios.

  • Post-thrombolysis management still requires definitive PCI in complex CAD.

FAQs

1. What is in-stent restenosis (ISR)?

ISR is the re-narrowing of a previously stented artery due to tissue growth inside the stent. It can lead to recurrent symptoms or even a heart attack, as seen in this case.

2. Why was IVUS used in this case?

IVUS allowed real-time imaging from inside the artery, ensuring precise stent sizing and expansion, which is crucial in high-risk zones like the left main artery.

3. What is the purpose of using DEBs (Drug-Eluting Balloons)?

DEBs deliver anti-proliferative drugs to the vessel wall without leaving a stent behind, reducing metal burden—ideal in previously stented or small vessels.

4. How does the Impella device help during PCI?

Impella supports the heart’s pumping function during high-risk procedures. It improves organ perfusion and reduces heart strain, especially in cardiogenic shock.

5. Can patients recover fully after such severe events?

Yes, with timely intervention, mechanical support, and comprehensive care, many patients recover well. However, long-term cardiac function depends on the extent of muscle damage.

6. What is the difference between CRRT and regular dialysis?

CRRT (Continuous Renal Replacement Therapy) is used in critically ill patients. It’s gentler and runs 24/7, making it suitable for unstable patients like those in shock.

7. What causes congestive hepatitis?

It occurs when reduced cardiac output leads to liver congestion. It often presents in cardiogenic shock and usually resolves as cardiac function improves.

8. What is the prognosis after Impella-supported PCI?

While prognosis depends on underlying heart function and organ recovery, Impella can improve procedural safety and survival in high-risk cases.