A Case Report of Immediate Extubation Post Primary PCI in STEMI

C l i n M e d International Library Citation: Ponniah SR, Ghosh P, Nagajothi N, Satti S, Nidamanuri K, et al. (2014) A Case Report of Immediate Extubation Post Primary PCI in STEMI.Int J Clin Cardiol 1:014 Received: November 16, 2014: Accepted: December 13, 2014: Published: December 16, 2014 Copyright: © 2014 Ponniah SR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Ponniah, et al. Int J Clin Cardiol 2014, 1:2 ISSN: 2378-2951


Introduction
Cardio-respiratory arrest secondary to STEMI is not uncommon.However, the optimal time to extubation following primary PCI in a cardiac arrest scenario is unclear.Here, we present a case of immediate extubation following primary PCI in a patient presenting with cardio-respiratory failure secondary to STEMI.

Case Description
A 59-year-old Caucasian male with recent history of non-ST elevation myocardial infarction (NSTEMI) 2 weeks ago, presented to the emergency department with complaints of chest pain.Other significant past medical history included chronic obstructive pulmonary disease, bladder cancer receiving chemotherapy, and lung cancer and noninsulin dependent type II diabetes mellitus.During his recent NSTEMI, coronary angiography showed a 95% lesion in the mid-left circumflex artery, which was thought to be the culprit lesion.There was also a 60-70% stenosis in the mid-segment of the right coronary artery and a 60-70% narrowing in the mid and distal left anterior descending artery.The patient underwent successful PCI with a bare metal stent to his left circumflex artery lesion.His discharge medication included Aspirin 325 mg daily, Plavix 75mg daily, metoprololtartrate 12.5mg twice daily, Coronary angiogram revealed 100% in-stent occlusion in the mid portion of left circumflex artery (Figure 2).The patient underwent successful thrombectomy and percutaneous intervention with a drug eluting stent (Figure 3).The patient stabilized hemodynamically post revascularization with resolution of arrhythmia.An intra-aortic balloon pump was therefore not required.
Post-procedure, the patient remained hemodynamically stable, chest pain free, was awake and following commands appropriately.There were no signs of acute congestive heart failure.Due to these reasons, we made the decision to immediately extubate him while in the cardiac catheterization laboratory.The extubation was successful.
The remainder of his hospital stay was uneventful.His cardiac troponin I peaked at 86.8mg/dl and an echocardiogram done 48 hours after the event revealed normal left ventricular systolic and diastolic function with no other abnormalities.He was maintained on dual anti-platelet therapy with Aspirin 81mg daily and Ticagrelor 90mg twice daily.He was discharged home after 4 days of hospitalization.

Discussion
Stent thrombosis is an uncommon but serious complication with an incidence of less than 1% [1].Most cases of stent thrombosis present with ST elevation myocardial infarction [2].Emergency PCI after stent thrombosis effectively restores vessel patency and flow [3].It is not uncommon to find cardiorespiratory instability in patients presenting with STEMI.Cardiorespiratory instability prior to PCI is an independent risk factor for increased mortality [4].Electrical instability of the myocardium during an acute coronary event can predispose to ventricular arrhythmias, especially ventricular fibrillation [5].Most of these patients presenting with cardiac arrest require cardio-respiratory support in the form of mechanical ventilation.The need for mechanical ventilation during the early management of STEMI is a strong prognostic indicator of mortality both at short and long term [6].The need for mechanical ventilation is also a predictor of depressed left ventricular function [5].The duration of mechanical ventilation is associated with long-term mortality [4].There are no standardized protocols to assess weaning in patients who undergo primary PCI.
Our patient needed ventilatory support due to cardiorespiratory collapse secondary to ventricular fibrillation from myocardialischemia.This was reversed with coronary re-vascularization.We feel that early extubation if possible is beneficial, considering that the duration of mechanical ventilation following STEMI strongly correlates with long-term mortality [4].The decision to extubate was made as per the recommended clinical criteria [7].

Conclusion
The duration of mechanical ventilation in patients presenting with STEMI is an independent predictor of long-term mortality.Patients who have undergone successful re-vascularization after STEMI with resolution of cardio-respiratory collapse should be assessed for extubation as soon as possible.We believe this will lead to a significant mortality benefit in these patients.Further studies are needed in this regard.

Figure 1 :
Figure 1: Patient's electrocardiogram at presentation reveals sinus rhythm with 4mm ST elevation in leads II, III, aVF and ST depression in leads V1 through V4.

Figure 3 :
Figure 3: Coronary angiogram post PCI and stent deployment with TIMI 3 flow distally in the left circumflex artery.

Figure 2 :
Figure 2: Coronary angiogram at presentation reveals total occlusion in the mid portion of left circumflex artery.