A 49-year-old man with pulmonary edema and cardiogenic shock due to acute inferior myocardial infarction was successfully treated with percutaneous transluminal coronary angioplasty supported by percutaneous cardiopulmonary bypass. Emergency diagnostic coronary angiography revealed nearly complete obstruction in segment (seg) 2 of the right coronary artery (RCA), 99% stenosis with delayed filling of contrast medium in seg 6 of the left anterior descending artery (LAD), and hypoplasty of the circumflex artery except in seg 12 with 75% stenosis. Both the LAD and seg 12 arteries provided fairly good collateral circulation to segs 3 and 4, while the septal branches of the LAD were poorly perfused by the conus branch of the RCA. The shock in this case was pathophysiologically characterized as pump failure of the functioning heart due to multivessel disease, which affected the infarcted but stunned inferior myocardium and the severely acute ischemic anterior myocardium. Percutaneous cardiopulmonary bypass support was instituted because of poor left ventricular function revealed by echocardiogram (ejection fraction≤30%) and the high risk of hemodynamic collapse during angioplasty in segs 2 and 6 even with the combined use of intraaortic balloon counterpulsation and administration of cathecholamine. It is concluded that cardiopulmonary bypass can safely be instituted percutaneously to hemodynamically stabilize a patient in cardiogenic shock and facilitate potentially life-saving emergency complex coronary angioplasty.
