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Background: ST elevation myocardial infarction (STEMI) has traditionally been a relative contraindication for the utilization of rotational atherectomy (RA). However, in severely calcified lesions, RA may be necessary to facilitate stent delivery. Case summary: Three patients who present with STEMI are found to have severely calcified lesions on intravascular ultrasound. Equipment was unable to pass the lesions in all three cases. Rotational atherectomy was therefore performed to allow for stent passage. All three cases had achieved successful revascularization with no intraoperative or post-operative complications. The patients remained angina-free the rest of their hospitalization and at the 4 month follow-up. Discussion: Rotational atherectomy for calcific plaque modification during STEMI when equipment will not pass is a feasible and safe therapeutic option.
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1,1-Difluoroethane (DFE) cardiomyopathy results from the direct inhalation of toxic halogenated hydrocarbons. We present a case series of acute DFE cardiomyopathy illustrating the typical presentation of severe DFE cardiomyopathy along with a detailed description of its mechanism of injury. (Level of Difficulty: Advanced.).
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Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP), remains a significant cause of morbidity and mortality worldwide if left untreated. Therapies for the treatment of RV shock range from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.
