Myocardial Infarction

Case Study
Diagnosis:
A frail senior presented with residual weakness and loss of balance following a myocardial
infarction. Prior medical history includes rheumatoid arthritis and congestive heart failure related
to a grade IV ventricle.
Challenges and Strengths:
Patient lives alone in the community and is responsible for all housekeeping tasks.
Patient is eligible for housekeeping and grounds support through Veterans Affairs.
Patient still drives.
Patient is eligible for funding assistance to purchase a rollator through Veterans Affairs but has
not previously accessed the support.
Uncomplicated recovery from MI, but has ongoing symptoms of weakness and decreased
endurance.

Solution:
Rollator with 8” wheels, anatomical handles, and slow down brakes with removable storage
basket. This is a durable walking device, designed for use in the home and community.
The client was discharged from the local acute care hospital with a basic rollator rented through a
community agency. The rollator proved to function well within the client’s one level home. It fit
through each doorway used in the home.
Since discharge, the client reported he had used the rollator on a daily basis. He used the seat to
conserve energy while sponge bathing at the bathroom sink and for rest breaks when walking in
the community to meet with friends.
When the client was ready to purchase the rollator, anatomical handles and slow down brakes
were added to the prescription. The client required anatomical handles to reduce bilateral joint
pain in his wrists. The anatomical grip allowed his weight to be distributed through the palm of his
hand, sparing the wrist joints. The patient required “slow down” brakes to eliminate the need to
maintain a constant squeeze. “Slow down” brakes maintain a constant resistance on the wheels,
which can be adjusted to the capabilities of the patient. This patient was able to walk more
confidently, could lessen his grip, and remove his hands from the handles to interact with his
environment.
The client opted to purchase the removable basket. He removes the basket when at home
allowing for a tighter turning radius and uses the “seat” to carry items from one room to another.
The basket is more often used in the community to carry purchased or other needed items.
The client is able to independently lift his walker into the cut-out trunk of his vehicle but he often
car-pools with friends when going grocery shopping in order to have someone else lift his rollator
into the car. While his friends push the cart and carry his groceries, he is able to use the rollator
throughout the store, often using the seat on the rollator for rest breaks.
Case Study: Acute Myocardial Infarction Patient with an acute myocardial infarction and
cardiogenic shock receives heart transplant following BVS therapy
A 51-year-old female with a history of ischemic cardiomyopathy and end-stage heart failure
presented to a community hospital in acute cardiogenic shock following Acute Myocardial
Infarction. Cardiac catheterization revealed a 90% occlusion of the Left Main artery, and an 80%
occlusion of the RCA. An IABP was placed and the patient was taken to the operating room the
next morning for coronary artery bypass surgery. During the operative procedure, an ABIOMED
BVS 5000 LVAD was necessary in order to wean the patient from cardio-pulmonary bypass. After
seven days on BVS support, the patient was transported via ambulance to a regional cardiac
transplant center for further evaluation. Two days later the patient was transitioned to a longer
term cardiac assist device. One month later the pateint received a heart transplant and was
discharged to home some time later. She has since returned to her normal daily activities.
History
A 51-year-old female with a documented history of ischemic cardiomyopathy and end-stage heart
failure presented to a community hospital in acute cardiogenic shock following AMI. Cardiac
catheterization revealed a 90% Left Main lesion, and an 80% RCA lesion; LVEDP was 46 mm
Hg. An IABP was placed for stabilization and patient was taken to the operating room in the
morning for an urgent CABG. Co-morbidities included: hypertension, diabetes mellitus, morbid
obesity, and an active smoking history.
Operative Summary
Following induction, the patient exhibited marginal hemodynamics with PA pressures of 70/40,
systemic pressure of 65/40, and a CI of 1.8 L/min./m2. Hemodynamics were supported with
inotropic agents. TEE revealed LVEF of 20%. CABG x 4 was performed utilizing the LIMA and
saphenous vein. CPB was discontinued with multiple inotropic agents and TEE showed LVEF of
35%. After decannulation, the patient suffered hemodynamic collapse requiring the second return
onto CPB. Although the circumflex vessel was regrafted, the third attempt to come off CPB
proved unsuccessful, despite maximal inotropic and IABP support. An ABIOMED BVS LVAD was
placed via the right superior pulmonary vein with a 32 Fr. Atrial Cannula, and the ascending aorta
was grafted with a 10 mm Hemashield™.
Post-Operative
After 7 days on BVS LVAD support, the patient was transported via ambulance on to a regional
cardiac transplant center for further evaluation. Two days later, the patient was taken to the
operating room. An echocardiogram demonstrated global left ventricular failure and MR. The BVS
LVAD served as a staging device to the implantation of the HeartMate as a bridge to transplant
LVAS. One month later a donor heart became available and the patient underwent orthotopic
heart transplantation without complication. The remainder of her hospital stay was uneventful and
she was discharged home. She has resumed her daily activities with no restrictions.
Patient Data
Indication for Use:AMI/Acute Cardiogenic Shock/ Post Cardiotomy
Type of BVS support: LVAD, 9 day duration
Age: 51 Sex: F Weight: 96 kg BSA: 2.00 m2
Surgical Data
Surgical Procedure: CABG x 4/LIMA
Total CPB time: 175 min.
Attempts to wean CPB: 3
IABP and multiple inotropes prior to LVAD: Yes
Cannulation LVAD: Right SPV - 32 Fr. Atrial; Ascending Aorta- 10 mm. Arterial
Patient Hemodynamics
Pre Implant On BVS Support
MAP: 59 79
RAP: 23 21
PAP: 70/40 45/20
CI: 1.8 2.2
EF: 20% NA
Organ Function
Liver: normal
Kidney: BUN=16, creatinine = 1.8

Anticoagulation Therapy
Initiation time: 10 hours post implant
ACT range: 180-210 sec.