Therapeutic hypothermia in combination with percutaneous coronary intervention in out-of-hospital cardiac arrest due to left main coronary artery disease

A 59-year-old man had a witnessed collapse while driving a car. Approximately 10 min after the call to emergency services, paramedics arrived and initiated cardiopulmonary resuscitation. The first electrocardiogram (ECG) obtained by paramedics showed pulseless electrical activity. Review of his prehospital records documented that he experienced approximately 13 min of no flow or low flow before return of spontaneous circulation. On admission, he was still comatose with midrange dilated pupils. Electrocardiogram showed sinus rhythm, ST segment elevation in lead aVR, and ST segment depression in leads I, II, and V4-6. Coronary angiography showed 99% narrowing of the left main coronary artery (LMCA), but did not show any disease in the right coronary artery. A bare-metal stent was placed in the LMCA, and postdilated at 20 atmospheres. Immediately after return to the coronary care unit, therapeutic hypothermia was initiated. Hypothermia with a target temperature of 33.0°C was maintained for 30 h. During this period, no significant hemodynamic instability occurred under intra-aortic balloon pumping (IABP) and intravenous catecholamines. Subsequently, he was slowly rewarmed at a rate of 0.3°C/h up to 36.0°C. Next day, the neurological condition improved and IABP was stopped. Creatine kinase increased to 2182 IU/l. Stent thrombosis did not occur despite the ad hoc loading of antiplatelet drugs. Follow-up echocardiography 9 days later showed mild hypokinesia of the anterior wall with an ejection fraction of 77%. He was discharged with no neurologic complications 18 days later.