A Shocking Case of Recovery in a Young Patient on ECPELLA Support
Presenter
Raghav Gattani, MBBS, Inova Heart and Vascular Institute, Fairfax, VA
Raghav Gattani, MBBS1, Behnam N. Tehrani, M.D.2, Palak Shah, MD, MS2, Aditya Dewanjee, BS3, Shashank Desai, M.D.4, Edward Howard5, Jamie Kennedy, MD6, Chriistopher S King, MD2, Hala Moukhachen4, Mitchell Psotka, MD, PhD, MPH7, Anika Raja, BS, MPH2, Ramesh Singh, MD2, Daniel Tang, MD6, Karl Young, PA8, Carolyn M. Rosner, MSN, RN, FNP-BC4, Moemen Eltelbany, MD6 and Shashank Sinha, MD, MSc9, (1)Inova Heart and Vascular Institute, Fairfax, VA, (2)Inova Heart and Vascular Institute, Oakton, VA, (3)University Of Virginia School of Medicine, Charlottesville, VA, (4)Inova Fairfax Hospital, Falls Church, VA, (5)Virginia Heart, Arlington, VA, (6)Inova Heart and Vascular Institute, Falls Church, VA, (7)INOVA Heart and Vascular Institute, Falls Church, VA, (8)Dave Young, Annandale, VA, (9)Inova Health System, Falls Church, VA
Title
A Shocking Case of Recovery in a Young Patient on ECPELLA Support
Introduction
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized in patients with refractory heart failure cardiogenic shock (HF-CS). Observational studies have described VA-ECMO support as a potential “bridge” to durable cardiac replacement therapies. We describe a case of a young woman with Society of Cardiovascular Angiography and Intervention (SCAI) Stage E HF-CS requiring VA-ECMO with subsequent myocardial recovery.
Clinical Case
A 37-year-old morbidly obese woman (BMI 58 kg/m
2) with ACC/AHA Stage D non-ischemic cardiomyopathy (left ventricle ejection fraction (LVEF) 15%) and persistent atrial fibrillation presented to the hospital with acute onset dyspnea. In the past year, she had multiple ER visits and hospitalizations for HF exacerbation. Her initial vitals demonstrated blood pressure 90/60 mmHg, atrial fibrillation at 131 beats per minute, and hypoxia requiring 4 liters/minute oxygen. On examination, she was lethargic, had elevated jugular venous pressure and cool extremities. Laboratory findings were significant for a NT-proBNP 9646 pg/ml, creatinine of 2.5 mg/dl, and lactic acid of 2.3 mmol/L. She was started on norepinephrine and admitted to the cardiac intensive care unit. She had rapid clinical deterioration requiring escalating doses of vasopressors. An emergent right heart catheterization demonstrated with a right atrial pressure 40 mm Hg, pulmonary capillary wedge pressure 45 mm Hg, pulmonary artery saturation 24%, and a Fick cardiac index 1.0 L/min/m
2. A multidisciplinary shock team was convened, and the consensus decision was made to escalate hemodynamic support to VA-ECMO. An intraoperative transesophageal echocardiogram (TEE) demonstrated severe biventricular dysfunction with severely dilated LV (LVIDd 8.9 cm). Due to minimal LV pulsatility, an Impella CP® was inserted for LV venting. The patient had a protracted hospital course complicated by incessant ventricular arrhythmias, multifocal pneumonia and oliguric renal failure requiring initiation of continuous renal replacement therapy. On hospital day 28, she was taken to the operating room for a planned HeartMate 3 LVAD and temporary RVAD placement. A ramp study was conducted and intraoperative TEE demonstrated an improved LVEF to 30% with marked reduction in LV cavity size to 5.5 cm and improvement of RV function. Given evidence of myocardial recovery, she was decannulated from VA-ECMO. The Impella CP® was removed on hospital day 31 and inotropes were weaned on hospital day 36. Subsequent cardiac MRI showed significant myocardial recovery with an LVEF of 45%. She was discharged home on guideline directed medical therapy on hospital day 45.
Discussion
CS is a hemodynamically complex and multifactorial syndrome with high morbidity and mortality. Although studies have focused on acute myocardial infarction-cardiogenic shock (AMI-CS), HF is increasingly recognized as the predominant CS phenotype. Recent observational data suggests that nearly 70% of SCAI C HF-CS patients may require escalation of circulatory support to VA-ECMO as a potential “bridge” to decision or definitive therapy. Our case highlights how VA-ECMO and other forms of temporary circulatory support may be used to bridge patients to recovery. Further research is needed to better understand the clinical predictors of myocardial recovery in CS patients requiring temporizing MCS.