Catheterization and Cardiovascular Interventions 85:828–831 (2015)
Case Report Abciximab-Induced Alveolar Hemorrhage Treated With Rescue Extracorporeal Membranous Oxygenation Andrew W. Choi,1 BS, John E.A. Blair,2* MD, and James D. Flaherty,3 MD We describe a case of a 75-year-old woman presenting emergently with an anterior S-T elevation myocardial infarction that deteriorated into ventricular fibrillation requiring prompt resuscitation, resulting in cardiogenic shock. Emergency primary percutaneous coronary intervention of the left anterior descending coronary artery with adjunctive abciximab and heparin resulted in adequate coronary flow, and intra-aortic balloon pump was used to support hemodynamics. Within one hour of intervention, she developed acute respiratory distress with four-quadrant opacification of lung fields, difficulty with oxygenation, and hypotension. Emergency bronchoscopy revealed diffuse erythematous proximal airways with bloody secretions bilaterally confirming diffuse alveolar hemorrhage. An emergency veno-arterial extracorporeal membranous oxygenation (ECMO) circuit was placed at the bedside, acutely improving oxygenation and hemodynamics. She survived the hospitalization with multiple complications related to access site and prolonged intensive care unit stay, was discharged to acute rehabilitation. She is currently thriving 18 months post-procedure. This case highlights the use of ECMO in the often-fatal condition of diffuse alveolar hemorrhage related to glycoprotein inhibitor use. VC 2014 Wiley Periodicals, Inc. Key words: ECMO; STEMI; primary PCI; cardiogenic shock; alveolar hemorrhage; coronary artery disease
INTRODUCTION
CASE REPORT
Diffuse alveolar hemorrhage is a rare complication of glycoprotein (GP) IIb/IIIa inhibitors. It has been associated with all three approved GP IIb/IIIa inhibitors, with respective incidences of 0.7%, 0.5%, and 0.9% for abciximab, eptifibatide, and tirofiban respectively in one case series [1]. The overall prognosis of alveolar hemorrhage due to GP IIb/IIIa inhibitors is poor, with a reported mortality of 20–50% in small case series [2–4]. Treatment for pulmonary hemorrhage has traditionally been supportive. A high index of suspicion followed by prompt diagnosis by bronchoscopy, as in the current case, is necessary as cardiorespiratory collapse can be quite sudden. Prompt discontinuation of GP IIb/IIIa inhibitor is necessary, although the antiplatelet effect may remain for days. Blood transfusions are often required due to profuse alveolar bleeding, and platelet transfusions are often necessary to overcome the antiplatelet effects of nonsmall molecule agents such as abciximab [1]. We describe a case of acute myocardial infarction complicated by diffuse alveolar hemorrhage.
A 75-year-old woman presented to the emergency department after 45 min of substernal chest pressure, dizziness, and diaphoresis. Her medical history was
C 2014 Wiley Periodicals, Inc. V
1
Northwestern University Feinberg School of Medicine, Chicago, Illinois 2 Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois 3 Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine Conflict of interest: Nothing to report. *Correspondence to: John E.A. Blair, MD, Assistant Professor of Medicine, Interventional Cardiologist, University of Chicago Medicine, 5841 South Maryland Avenue, MC5076, Room M530, Chicago, IL 60637. E-mail: [email protected] Received 4 August 2014; Revision accepted 2 November 2014 DOI: 10.1002/ccd.25731 Published online 8 November 2014 in Wiley Online Library (wileyonlinelibrary.com)
Alveolar Hemorrhage and rescue ECMO
significant only for breast cancer 6 years prior, in remission after chemo- and radiation-therapy. She had no family history of coronary artery disease, and no history of tobacco use. She was not taking any prescription medications. She had a blood pressure of 120/67 mm Hg, a heart rate of 72 beats per minute, a respiratory rate of 18 breaths per minute, and pulse oximetry of 98%. On examination, she had a regular heart rate, normal heart sounds, clear lungs, no jugular venous distention, and normal neurological examination. Electrocardiogram demonstrated sinus rhythm and 4 mm S-T segment elevations in the anterior precordial leads, followed by the development of a left bundle branch block. Shortly after presentation, she developed ventricular fibrillation requiring advanced cardiac life support and defibrillation with 200 Joules of biphasic energy. She was intubated, given aspirin 324 mg via nasogastric tube, and taken to the cardiac catheterization laboratory. During transportation to the cardiac catheterization laboratory, she developed complete heart block, with a slow ventricular escape and profound hypotension. A temporary pacemaker was placed, which improved hypotension. Angiography revealed a 100% thrombotic occlusion of the proximal left anterior descending coronary artery, a focal 30% lesion in the ostial left circumflex coronary artery, and a focal 50–60% lesion in the mid right coronary artery. Due to extensive thrombus burden, she was given intravenous abciximab 0.75 mg/kg, intravenous heparin 60 units/kg, and clopidogrel 600 mg via nasogastric tube, and underwent percutaneous coronary intervention with a drug-eluting stent in her proximal left anterior descending coronary artery resulting in thrombolysis in myocardial infarction (TIMI) grade 3 flow. During the intervention, complete heart block eventually resolved and the temporary pacemaker was placed on standby. An intra-aortic balloon pump (IABP) was placed during the intervention due to the presence of systolic blood pressure
Case Report Abciximab-Induced Alveolar Hemorrhage Treated With Rescue Extracorporeal Membranous Oxygenation Andrew W. Choi,1 BS, John E.A. Blair,2* MD, and James D. Flaherty,3 MD We describe a case of a 75-year-old woman presenting emergently with an anterior S-T elevation myocardial infarction that deteriorated into ventricular fibrillation requiring prompt resuscitation, resulting in cardiogenic shock. Emergency primary percutaneous coronary intervention of the left anterior descending coronary artery with adjunctive abciximab and heparin resulted in adequate coronary flow, and intra-aortic balloon pump was used to support hemodynamics. Within one hour of intervention, she developed acute respiratory distress with four-quadrant opacification of lung fields, difficulty with oxygenation, and hypotension. Emergency bronchoscopy revealed diffuse erythematous proximal airways with bloody secretions bilaterally confirming diffuse alveolar hemorrhage. An emergency veno-arterial extracorporeal membranous oxygenation (ECMO) circuit was placed at the bedside, acutely improving oxygenation and hemodynamics. She survived the hospitalization with multiple complications related to access site and prolonged intensive care unit stay, was discharged to acute rehabilitation. She is currently thriving 18 months post-procedure. This case highlights the use of ECMO in the often-fatal condition of diffuse alveolar hemorrhage related to glycoprotein inhibitor use. VC 2014 Wiley Periodicals, Inc. Key words: ECMO; STEMI; primary PCI; cardiogenic shock; alveolar hemorrhage; coronary artery disease
INTRODUCTION
CASE REPORT
Diffuse alveolar hemorrhage is a rare complication of glycoprotein (GP) IIb/IIIa inhibitors. It has been associated with all three approved GP IIb/IIIa inhibitors, with respective incidences of 0.7%, 0.5%, and 0.9% for abciximab, eptifibatide, and tirofiban respectively in one case series [1]. The overall prognosis of alveolar hemorrhage due to GP IIb/IIIa inhibitors is poor, with a reported mortality of 20–50% in small case series [2–4]. Treatment for pulmonary hemorrhage has traditionally been supportive. A high index of suspicion followed by prompt diagnosis by bronchoscopy, as in the current case, is necessary as cardiorespiratory collapse can be quite sudden. Prompt discontinuation of GP IIb/IIIa inhibitor is necessary, although the antiplatelet effect may remain for days. Blood transfusions are often required due to profuse alveolar bleeding, and platelet transfusions are often necessary to overcome the antiplatelet effects of nonsmall molecule agents such as abciximab [1]. We describe a case of acute myocardial infarction complicated by diffuse alveolar hemorrhage.
A 75-year-old woman presented to the emergency department after 45 min of substernal chest pressure, dizziness, and diaphoresis. Her medical history was
C 2014 Wiley Periodicals, Inc. V
1
Northwestern University Feinberg School of Medicine, Chicago, Illinois 2 Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois 3 Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine Conflict of interest: Nothing to report. *Correspondence to: John E.A. Blair, MD, Assistant Professor of Medicine, Interventional Cardiologist, University of Chicago Medicine, 5841 South Maryland Avenue, MC5076, Room M530, Chicago, IL 60637. E-mail: [email protected] Received 4 August 2014; Revision accepted 2 November 2014 DOI: 10.1002/ccd.25731 Published online 8 November 2014 in Wiley Online Library (wileyonlinelibrary.com)
Alveolar Hemorrhage and rescue ECMO
significant only for breast cancer 6 years prior, in remission after chemo- and radiation-therapy. She had no family history of coronary artery disease, and no history of tobacco use. She was not taking any prescription medications. She had a blood pressure of 120/67 mm Hg, a heart rate of 72 beats per minute, a respiratory rate of 18 breaths per minute, and pulse oximetry of 98%. On examination, she had a regular heart rate, normal heart sounds, clear lungs, no jugular venous distention, and normal neurological examination. Electrocardiogram demonstrated sinus rhythm and 4 mm S-T segment elevations in the anterior precordial leads, followed by the development of a left bundle branch block. Shortly after presentation, she developed ventricular fibrillation requiring advanced cardiac life support and defibrillation with 200 Joules of biphasic energy. She was intubated, given aspirin 324 mg via nasogastric tube, and taken to the cardiac catheterization laboratory. During transportation to the cardiac catheterization laboratory, she developed complete heart block, with a slow ventricular escape and profound hypotension. A temporary pacemaker was placed, which improved hypotension. Angiography revealed a 100% thrombotic occlusion of the proximal left anterior descending coronary artery, a focal 30% lesion in the ostial left circumflex coronary artery, and a focal 50–60% lesion in the mid right coronary artery. Due to extensive thrombus burden, she was given intravenous abciximab 0.75 mg/kg, intravenous heparin 60 units/kg, and clopidogrel 600 mg via nasogastric tube, and underwent percutaneous coronary intervention with a drug-eluting stent in her proximal left anterior descending coronary artery resulting in thrombolysis in myocardial infarction (TIMI) grade 3 flow. During the intervention, complete heart block eventually resolved and the temporary pacemaker was placed on standby. An intra-aortic balloon pump (IABP) was placed during the intervention due to the presence of systolic blood pressure
