A successful team treatment for left main shock syndrome
A 59 year-old male was admitted to our hospital experiencing recurrent chest pain for 6 years and severe pain for 10 h. He had been smoking for seven years and had prior 5 years history of hypertension (160/90 mmHg). On physical examination, the patient was clammy and normal blood pressure (115/60 mmHg), with normal heart sounds and bilateral pulmonary rales on the lower zone of lungs. His electrocardiogram demonstrated ST segment elevation in leads I, aVL, aVR, V1 through V4, ST segment depression in lead II, III and aVF (). Chest X ray indicated a minor increase in pulmonary markings. Acute anterioseptal and lateral myocardial infarction (Killip Class II) and hypertension were diagnosed and the patient was immediately transferred to the catheterization laboratory from the emergency unit. 300 mg aspirin, 600 mg loading dose of clopidogrel and 5000 U of intravenous heparin were administered.\nAs soon as the coronary angiography was performed, the blood pressure of the patient had dropped to 80/50 mmHg with dyspnea. Coronary angiography disclosed a left main occlusion in the middle portion of its body and a severe stenosis at the proximal posterior descending artery of right coronary artery ().\nWe decided to perform PCI on LMCA. At first, intra-aortic balloon pump (IABP) was inserted and the blood pressure was increased to 95/50 mmHg, except for severe hypoxemia. So an extracorporeal membrane oxygenation machine (ECMO) was inserted via left femoral venoarterial access. The blood pressure was increased to 105/50 mmHg after a while. After one coronary soft guide wire (0.014 inch run through; teromo, Japan) had been passed into the left anterior descending (LAD) coronary arteries, the distal left main portion and LAD was predilatated with 1.5 × 15 mm balloon inflated at 16 atm. Subsequently, LAD was dilatated with SPRINTER 2.0 × 12 mm balloon inflated at 14 atm and a FIRE STAR 2.5 × 15 mm balloon inflated at 14 atm. Distally to this lesion with Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow, both LAD and diagonal branch presented a significant diffuse lesion while circumflex (CX) ostia presenting with coronary aneurysm (). Therefore, we ended the procedure.\nThe patient was then monitored in Coronary heart disease Care Unit (CCU) with 3.4 L/min of Extracorporeal Membrane Oxygenation (ECMO) and 1: 1 counterpulsation of IABP supporting on the first day after PCI. The total 24 h urine volume increased from 1050 mL of the second day to 3170 mL of the third day after PCI. So the IABP was withdrawn and ECMO volume was turned down to 2.4 L/min.\nHowever, the number of platelets in the whole blood of the patient dropped from 140 G/L on the first day to 76 G/L on the fifth day with normal liver, kidney and blood clot function, a successively CABG (AO-SVG-LAD and AO- SVG-D1-PDA) was then performed. On the second day after CABG, ECOM was withdrawn successfully. The patient is now on his three month uneventful follow-up.