Title:
Use of ECPELLA in Management of Cardiogenic Shock
Sudarshana Datta, Anju Bhardwaj, Sachin Kumar, Angelo Nascimbene, Ismael Salas de Armas, Manish Patel, Igor Gregoric, Biswajit Kar Introduction
Cardiogenic Shock (CS) is the leading cause of in-hospital mortality following acute myocardial infarction (MI). In the following case, we outline an approach to the management of CS complicating acute MI highlighting importance of invasive hemodynamics and use of mechanical circulatory support (MCS) devices such as Venoarterial- extracorporeal membrane oxygenation (VA- ECMO) and ECPELLA (ECMO+Impella) and discuss use of temporary MCS as bridge to decision.
Clinical Case
A 40 year old male with history of coronary artery disease (CAD), diabetes and hypertension presented with acute anterior ST elevation MI. Cardiac catheterization revealed severe multivessel disease with left anterior descending artery being the culprit vessel. He underwent percutaneous coronary angioplasty with drug eluting stent to LAD, balloon angioplasty to previous distal LAD stent; an intra aortic balloon pump (IABP) was placed due to elevated left ventricular end diastolic pressure (~ 30 mm Hg) and large ischemic burden and he was transferred to intensive care unit. Echo showed LV ejection fraction 30-35%, with normal LV dimensions, global hypokinesis with hypokinesis to akinesis of septum & apex, and normal right ventricular size and function. Overnight, the patient became hypotensive, was started on levophed, with worsening O2 requirements and subsequently decompensated requiring intubation. The patient, who had initially presented in SCAI Stage B cardiogenic shock progressed to stage D shock with hemodynamic deterioration. He was emergently cannulated with ECMO at bedside and thereafter his hemodynamic parameters improved. Subsequently, he underwent Impella 5.5 placement, IABP was removed and and was weaned off ECMO thereafter. However, he remained dependent on Impella. His course was later complicated by Impellar thrombosis due to an apical LV thrombus. He decompensated and was emergently placed on ECMO. The Impella was removed. Later was noted to have worsening O2 requirements due to ECMO lung so an Impella 5.5 was reinserted to enable LV venting after confirming resolution of apical thrombus. While the ECMO was successfully decannulated, we were unable to wean off Impella despite multiple attempts. Therefore, the decision was made to proceed with durable left ventricular assist device (LVAD) placement. He was discharged home after a prolonged course and continues to follow with LVAD clinic. He is currently being worked up for heart transplant.
Discussion
In this case we highlighted a patient who presented with CS with a 'reversible’ or ‘fixable’ cause. He presented with ‘SCAI stage B’ and subsequently deteriorated to ‘SCAI stage D’ requiring escalation of MCS. We also underscored the importance of invasive hemodynamic assessment and monitoring in management of CS. Early and timely initiation of MCS is associated with improved outcomes. We also reviewed the role of temporary MCS as a bridge to recovery, bridge to advanced therapy or as a bridge to decision just like in our patient presented above. Furthermore, we also alluded to complications associated with ECMO and discussed improved survival on ECPELLA rather than Impella alone.