Intra-aortic Balloon Pump in Acute Myocardial Infarction and Ischemic Mitral Insufficiency

A 71-year-old woman got the emergency unit reporting a chest pain in the last 24 h, which started at dawn and was characterized as burning, radiating to the jaw and back, associated with diaphoresis and nausea. She was hemodynamically stable, breathing spontaneously in a comfortable pattern, referring nausea and didn’t have any abnormalities at the physical exam. Her medical history was positive to arterial hypertension, type 2 diabetes mellitus, dyslipidemia, and obesity class II. She also was a smoker for 30 years. The electrocardiography (ECG) showed ST elevation in inferior and anterior walls, so acute coronary syndrome (ACS) protocol was initiated and transfer requested, with no report of thrombolysis. A coronarography showed an occlusion of the middle segment of right coronary artery (RCA) with thrombus image, an occluded circumflex artery, and anterior descending artery (ADA) with middle segment lesion 50–75% and 90% average distal lesion. It was prescribed anticoagulation for 7 days. Ten hours after she had arrived at the emergency, she got hemodynamic instability, tending to hypotension and uncomfortable ventilation pattern, thus starting noninvasive ventilation. Besides this, she presented with worsening of hypotension and needed vasoactive drugs. Two and a half hours later, she did the second coronarography, which showed a severe three-vessel obstructive pattern, with diffuse involvement of coronaries. An intra-aortic balloon pump was introduced. She maintained unstable hemodynamics in use of noradrenaline and dobutamine but a comfortable ventilation pattern on mechanical ventilation and good gas exchange analysis. An echocardiogram showed mild aortic and tricuspid insufficiency, moderate mitral regurgitation with moderate regurgitation fraction, lower akinesia of the left ventricle, mild/moderate pulmonary hypertension, and left ventricular ejection fraction of 55%. After discussion with the surgical team, conservative treatment was chosen. The patient kept hemodynamic instability and presented with anuria, pulmonary congestion, and a drop in blood pressure, refractory to vasoactive amines with subsequent cardiac arrest. The patient died.