1. CASE PRESENTATION Clifford J Kavinsky, MD, PHD Professor of Medicine and pediatrics Associate Director, Center for Congenital and Structural Heart Disease Rush University Medical Center

2. S.C. 60 year old gentleman with a history of hypertension Had an episode of sudden chest pain at work followed by a syncopal episode Was given 4 baby aspirins en route to hospital EMS noted his blood pressure to be 70/palp and he appeared to be diaphoretic, mentating appropriately

3. ED Assessment Vitals: BP: 60/0, Pulse: 95,Resp: 27, Weight: 58.968 kg, SpO2: 90% (100% NRB) Patient’s chest pain had improved but he was having significant shortness of breath He appeared distressed, diaphoretic and pale, mentation was intact.

4. Admission 12-Lead Electrocardiogram

5. Hospital Course STEMI Pager Activated Received Effient 60 mg and Aspirin 325 mg in the ED Dopamine drip started Patient transported to cath lab 8 minutes after arrival in the ED

6. Coronary Angiogram

7. Right Coronary Artery

8. Cardiac Catheterization Laboratory Patient was given 5,000 Units of IV Heparin Balloon angioplasty of the LM Stenting of LM with 3.5 X 18 mm BMS

9. Cardiac Catheterization Laboratory

11. Patient remained hemodynamically unstable throughout the procedure, requiring escalation of vasopressors Multiple episodes of VT/VF requiring DCCV, Amiodarone and Lidocaine infusions Endotracheal intubation and mechanical ventilation Pacing catheter inserted into the RV 2.5 L Impella device was inserted into the LV Cardiac Catheterization Laboratory

14. Post-Procedure Transthoracic Echo

17. Hospital Course Patient transferred to CCU with Impella in place, multiple pressors, intubated Patient’s mean arterial pressure remained low and flows on Impella were low CV surgery evaluated the patient and urgently placed him on ECMO at the bedside Patient continued to require full ECMO support, was taken to OR for LVAD (Heart Mate II) placement 5 days following presentation

18. Hospital Course Patient with multiple complications including – left upper extremity compartment syndrome (thought to be secondary to hematoma/arterial line attempt while on full dose anticoagulation) – Left lower extremity ischemia (embolic) sp embolectomy – Right upper extremity ischemia (embolic) sp catheter directed lysis – Fever of unknown origin – Bleeding requiring numerous blood products – Atrial fibrillation Tracheostomy and PEG tube placement Neurologically intact UNOS status 7 for OHT

19. Thank you