Thank you for inviting me and the opportunity to present this case. These are my disclosures, not relevant to the case I'll be presenting. Truly say, like Sarah mentioned earlier, my real disclosure is that I train in both interventional and critical care, so I spend most of the time arguing with myself about what to do about the patient. So this is a 57-year-old man who's got an unknown past medical history, actually collapsed at home, witnessed by his wife, she heard a thud, immediately alerted EMS and she began bystander CPR. EMS found him to be in ventricular fibrillation, performed three defibrillations and brief CPR. ROSC was achieved, and en route to the EKG, to AGH, he had this EKG, which is a not-so-subtle anterior and anterolateral STI elevation EKG, which was concerning for a STEMI, but unfortunately this patient actually required recurrent defibrillations in the emergency room and CPR was re-initiated, so at our institution we have a level 1 ECMO alert, which is an eCPR activation, and he was emergently cannulated for VA ECMO at the bedside in the emergency room. Subsequently thereafter, we went to the cardiac catheterization lab and performed diagnostic angiography after the placement of an impella-CP catheter, which is often debated at our institution about what the next best steps are when you're on ECMO support, but based on some of his invasive hemodynamics with an LVDP of 36, the thought was placing that impella pre-PCI may mitigate some of that LV afterload from the ECMO circuit for the eCPR. IV cangular infusion was initiated for antiplatelet therapy and we proceeded with revascularization of the culprit lesion, which was thought to be the 100% occluded LAD, but on top of that there was a thrombotic occlusion at the distal left main that required additional revascularization and he actually underwent a pretty extensive left main bifurcation decay crush. I'll skip you the gory details of the actual intervention, but essentially, you know, optimization with intravascular imaging, kissing balloon inflation, POT, and final images of the bifurcation and the LAD with a pretty decent angiographic result, but we're not done there as you've heard it all for the last couple of days. The hemodynamics in the cath lab helped dictate what's the best next steps in the plan for this patient. So, it's a 57-year-old gentleman who suffered an out-of-hospital cardiac arrest in-hospital as well, secondary to acute myocardigenic shock, the left main LAD culprit. Now status post-successful echopella escalation and PCI, a PA catheter was placed and those were his invasive hemodynamics noted for low biventricular filling pressures, a normal cardiac output and index estimated by indirect FIC and a lactate of 15. So he's admitted subsequently to our cardiothoracic intensive care unit and goal targeted temperature management to 36 given the cardiac arrest that he had suffered and the advanced heart failure cardiac surgical teams have been consulted. And I'll pause right there.

ventricular fibrillation

anterior STEMI

VA ECMO

PCI

heart failure management