Key result
Reperfusion plus short-term Impella terminates refractory VF and resolves cardiogenic shock during complex PCI.
Why the study?
Refractory ischemia-mediated ventricular fibrillation during PCI is a life-threatening complication requiring rapid culprit identification and reperfusion, but practical case-based guidance on management and mechanical support is limited.
Case Report (n=1)
Refractory ischemia-driven intraprocedural ventricular fibrillation may terminate only upon mechanical culprit-vessel reperfusion and can be successfully managed with temporary microaxial flow pump support as an individualized rescue strategy.
May support individualized rescue with short-duration Impella plus reperfusion in refractory intraprocedural VF; case report leaves open need for prospective validation.
Background: Ventricular fibrillation (VF) is a life-threatening complication of acute coronary syndrome (ACS) and requires rapid identification and correction of reversible ischemic triggers. ST-segment elevation in aVR with diffuse ST depression reflects global subendocardial ischemia but is not specific for left main or proximal left anterior descending disease. Case Summary: A 62-year-old male with prior coronary stent placement presented with acute chest pain, diaphoresis, nausea, and vomiting. An electrocardiogram demonstrated ST-segment elevation in aVR with ST depressions in V3-V6. Laboratory testing demonstrated severe metabolic acidosis (pH 7.07; bicarbonate 10.3 mEq/L), lactate 3.7 mmol/L, and high-sensitivity troponin rising from 427 to 4991 ng/L within 2 h. During emergent angiography, VF developed after left ventricular catheter manipulation and recurred repeatedly while attempting to cross a heavily calcified 99% proximal left circumflex (LCx) lesion. Over 20-30 min, 11 VF episodes required immediate defibrillation, manual chest compressions, and intravenous amiodarone. VF ceased only after LCx stenting restored TIMI Grade 3 flow. The patient's maximum intraprocedural shock severity met SCAI Stage E criteria because of recurrent cardiac arrest, multiple defibrillations, and severe acidosis. An Impella microaxial flow pump was placed for temporary postresuscitation circulatory support and maintained at P4. A postreperfusion echocardiogram obtained during ongoing support showed an LVEF of approximately 60%. The device was removed within 48 h after hemodynamic recovery. Staged intravascular lithotripsy-assisted PCI of the calcified mid-LAD lesion was performed on Day 4. Discussion: This case demonstrates that refractory ischemia-mediated VF may terminate only after culprit-vessel reperfusion. A preserved LVEF measured after reperfusion during mechanical support does not exclude earlier SCAI Stage E shock. Short-duration Impella support may serve as an individualized bridge during recovery from recurrent arrest and transient circulatory collapse.
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Madishetty et al. (2026) conducted a case report in Acute coronary syndrome with refractory intraprocedural ventricular fibrillation (n=1). Culprit percutaneous coronary intervention and short-duration Impella support was evaluated on Termination of ventricular fibrillation and hemodynamic recovery. Culprit vessel reperfusion combined with short-duration Impella support successfully terminated refractory intraprocedural ventricular fibrillation and resolved cardiogenic shock.
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