Outpatient cardiac stress test to left atrial venoarterial extracorporeal membrane oxygenation: a dire ripple effect

SESSION TITLE: The Cardiac Intensivist 1 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Inappropriate nuclear cardiac stress testing happens at an approximate rate of 13-45% [1]. While non-invasive stress testing is relatively safe, inappropriate utilization can lead to unstable coronary disease and refractory cardiogenic shock. CASE PRESENTATION: A 53-year-old man presented for elective cardiac diagnostic testing (nuclear PET stress test and TTE) for ongoing dyspnea and orthopnea. While exiting the hospital, the patient became hypotensive, developed ventricular tachycardia and collapsed. Initial EKG was notable for sinus tachycardia, ST depressions in leads II and V6. The PET stress test showed a large reversible scar in the septum and apex with LVEF of 19%. Limited bedside echocardiogram revealed an LVEF of 15-20%. Emergent coronary angiography demonstrated a nearly occlusive thrombus in the proximal LCx with a completely occlusive proximal mid-LAD and proximal RCA. Subsequent hemodynamic compromise prompted emergent mechanical ventilation and mechanical circulatory support. Systemic perfusion and left ventricle (LV) offloading was considered to be best achieved by ECPELLA (venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella-CP). Unfortunately, official TTE revealed a large LV thrombus measuring 2.53 cm x 2.38 cm. The Impella-CP was exchanged for left atrial venoarterial extracorporeal membrane oxygenation (LAVA-ECMO). This was followed by a complex PTCA involving an aspiration thrombectomy in the LCx, rotational atherectomy and stenting of mid to distal LAD and a double kissing crush technique with stenting at the LM bifurcation. Follow-up TTE demonstrated stable LV thrombus with improved LVEF of 20-25%. Ultimately, this patient was successfully able to come off of LAVA-ECMO and completed a prolonged cardiac rehabilitation with impressive clinical recovery. DISCUSSION: Rapid advances in cardiovascular imaging modalities and increased clinical demand have raised many questions about inappropriate utilization of cardiac testing [2]. Inappropriate use of nuclear cardiac stress testing has been associated with limited clinical value, increased radiation exposure and unwarranted medical expenses [3]. This case highlights that inappropriate cardiac stress testing can result in acute decompensation, and its utility should be limited to patients at intermediate pretest probability for coronary artery disease. It also illustrates several key steps to improve clinical outcomes including (1) advantages and disadvantages of mechanical cardiac support with different types of ECMO and LV support devices, (2) recognition of contraindications to percutaneous LV assist device, and (3) importance of early escalation to biventricular support. CONCLUSIONS: Appropriate risk stratification is essential in the selection of diagnostic modality for the evaluation of coronary artery disease, as inappropriate testing can result in acute decompensation. Reference #1: Ye S, Rabbani LE, Kelly CR, et al. Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging. Circ Cardiovasc Qual Outcomes. 2015;8(1):23-29. doi:10.1161/CIRCOUTCOMES.114.001067 Reference #2: Iglehart JK. The new era of medical imaging--progress and pitfalls. N Engl J Med. 2006;354(26):2822-2828. doi:10.1056/NEJMhpr061219 Reference #3: Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009;361(9):849-857. doi:10.1056/NEJMoa0901249 DISCLOSURES: No relevant relationships by Akruti Prabhakar No relevant relationships by Brian Schwartz No relevant relationships by EricsonJohn Torralba No relevant relationships by Damian Valencia No relevant relationships by Yan Yatsynovich