A successful ERCP in a patient immediately after the PTCA for his recent MI

Arivarasan. K1, Joseph. T2

1Senior Consultant Gastroenterologist and Hepatologist, Kauvery Hospital, Cantonment, Trichy

2Interventional Cardiologist, Kauvery Hospital, Heart City, Trichy

Case Presentation

An 86-year-old male patient presented to the emergency department late evening with obstructive jaundice and cholangitis.

Within hours of admission, he experienced cardiac arrest, from which the emergency team successfully resuscitated him. The patient required intubation and inotropic support. Despite high-dose inotropic, he remained hypotensive (systolic blood pressure 60-70 mmHg) and anuric. ECG revealed an acute inferior wall myocardial infarction, and echocardiography demonstrated severe left ventricular dysfunction..

Following consultation with cardiologist, primary PCI was planned in view patient’s hypotension. The patient’s family was informed of the procedure’s risks, and the patient was subsequently transferred to the cardiac cath lab for primary PTCA at midnight.

The following morning, while still requiring high inotropic support, the patient demonstrated improved cardiac function, though oliguria persisted.

Deterioration was due to cholangitis. While percutaneous biliary drainage was considered, it was deemed inadvisable given the patient’s dual antiplatelet and anticoagulation regimen. Given the patient’s intubation and lack of alternative options, ERCP was undertaken despite its contraindication in recent myocardial infarction.

We anticipated that rapid biliary stenting, without cutting maneuvers, would be safe. With the assistance of our anaesthesiology team, the ERCP was completed in under five minutes, and the patient was safely returned to the ICU

The patient, under the critical care team’s supervision, was extubated within 24 hr, weaned from inotropic support, and transferred to the ward.

The patient was discharged ambulatory.

This exemplifies the remarkable outcomes achievable through effective teamwork, from the emergency room team’s efficient management of the cardiac arrest to cardiologist timely decision for primary PCI, to the anesthesiology team’s intervention, and the dedication of the critical care and nursing staffs.

Fig 1 (a), (b): Angiography

Fig 2 (C), (D), (E): ERCP Procedure

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