Native Heart Recovery in Peripartum Cardiomyopathy Complicated by Cardiogenic Shock: A Multidisciplinary Approach
Presenter
Brian Ssembajjwe, MD, Loma Linda University Health, Loma Linda, CA
Brian Ssembajjwe, MD1, Natthapon Angsubhakorn, MD1, Nicolas Kang, MD1, Nicole Lee, MD1, Pooja M. Swamy, MD, FSCAI1, Antoine Sakr, MD1, Reza Salabat, MD1, Joshua Chung, MD1, Diane Tran, MD1 and Dr. Aditya Bharadwaj, M.B.B.S., FSCAI2, (1)Loma Linda University Health, Loma Linda, CA, (2)Loma Linda University Medical Center, Riverside , CA
Title
Native Heart Recovery in Peripartum Cardiomyopathy Complicated by Cardiogenic Shock- A Multidisciplinary Approach Introduction
Peripartum Cardiomyopathy (PPCM) is a rare complication of pregnancy that may result in congestive heart failure, thromboembolism, cardiac arrhythmias, and potentially cardiogenic shock. Herein, we present a case of PPCM leading to cardiogenic shock supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and subsequently Impella 5.5, with successful recovery of native heart function. Clinical Case
A 31-year-old female with history of PPCM and reduced left ventricular ejection fraction (LVEF 15-20%) that was diagnosed 2 months earlier presented to the outside hospital with tachypnea and wheezing. She was found to be in cardiogenic shock with severe hypotension and impaired end organ perfusion (serum lactate: 23 mMol/L, serum creatinine of 2.2 mg/dL, aspartate aminotransferase 3,454 U/L, alanine transaminase 938 U/L, total bilirubin 2.5 mg/dL). Our institution (hub) was contacted for emergent transfer. Recognizing the acuity of the situation, she was expeditiously transferred to our institution. The patient arrived at our institution 3 hours later, intubated and was on high doses of intravenous norepinephrine and dobutamine. Emergent transthoracic echocardiogram (TTE) at our hospital showed LVEF of 10-15%. Given the patient’s hemodynamic instability, markedly decreased biventricular cardiac function, and severely elevated lactate, she was diagnosed with SCAI Stage D/E shock. Management at our institution involved an immediate multidisciplinary team approach that consisted of interventional cardiology, cardiothoracic surgery, and advanced heart failure for evaluation for the best MCS device at this point and consideration for advanced therapies. The decision was made to proceed to urgent VA-ECMO cannulation. Continuous renal replacement therapy (CRRT) was initiated on day 2 because the patient remained anuric. On day 3 there was consideration for Impella 5.5 for unloading of left ventricle. As the patient was being prepared for Impella 5.5 insertion, she was noted to have a large hematoma and concern for acute limb ischemia at the ECMO cannulation site. By day 4, her RV had improved, and oxygenation was better so a decision was made to decannulate ECMO and insert Impella 5.5 via right axillary artery. For the next 2 weeks, the patient continued to remain on Impella 5.5 support, with invasive hemodynamic monitoring and was unable to be weaned off support. She was subsequently listed for heart and kidney dual organ transplant but was unable to find a suitable match due to multiple antibodies. After 4 weeks the patient slowly began to regain pulsatility of her native heart and was able to come off of CRRT. On day 37, patient was successfully weaned off of Impella 5.5 with improved LVEF to 40%. Inotropic support was weaned off on day 45, and the patient was discharged on day 50 on guideline-directed medical therapy. LV function further improved with LVEF of 50-55% at one-year follow-up. Discussion
This case demonstrates the importance of timely identification of cardiogenic shock, ‘hub and spoke’ model to facilitate transfer, and a multidisciplinary management with protocol based, hemodynamic guided approach to MCS to improve outcomes in these sick patients.