Introduction: Myocardial Infarction (MI) occurs due to narrowing of the coronary vessels leading to ischemia. Unlike ST-segment elevation MI (STEMI), NSTEMI (Non-ST-segment MI) does not have ST-segment elevation on an electrocardiogram (ECG). Ventricular Fibrillation (V-Fib) often results from MI causing rapid and chaotic electrical activity in the ventricles which can lead to cardiogenic shock, the inability of the heart to properly perfuse organs. Management can include Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft (CABG). We present a unique case of cardiac arrest secondary to V-Fib in a patient diagnosed with
severe left main disease managed by PCI.

Case Presentation: 52-year-old Middle Eastern female with history of hyperthyroidism, tobacco use disorder, and obesity presented with cardiac arrest. Patient takes Methimazole 10 mg and recently discontinued Atorvastatin 80 mg due to transaminitis. Initial EKG revealed V-fib, and cardiopulmonary resuscitation (CPR) was promptly initiated. Defibrillation was performed, and ROSC was achieved after 4 rounds of CPR. Post ROSC EKG did not show any ST-segment elevation. The patient was intubated, started on Amiodarone, and transferred to the catheterization lab. Lab studies showed TSH <0.01 mIU/L, T4=2.16 μg/dL, Troponin=286
ng/L, WBC=22,700 × 109/L), Hg=9.1 g/dl), Creatinine= 0.44 mg/dL.

Final/Working Diagnosis: Coronary angiography confirmed the presence of 90% left main artery occlusion.

Management/Follow Up: Patient was successfully treated with PCI using a drug-eluting stent (DES). An Impella device was deployed during the procedure. Post-catheterization echocardiogram showed an ejection fraction (EF) of 31-35%. Impella device was removed the following day and the patient was successfully extubated. Subsequent echocardiogram showed an EF of 60%. The patient was initiated on Lisinopril, Aspirin, Atorvastatin, and Metoprolol Succinate.

Discussion: In this rare example of left main disease complicated by cardiac arrest and cardiogenic shock successfully treated with PCI and Impella rather than the more conventional CABG. There are growing numbers of case reports highlighting PCI over CABG for treatment of Left main disease. SYNTAX trial was a landmark trial which showed no difference in management. Similarly further trials are needed to allow for more standardized practice.

References and Resources

NA