Two Hearts in Shock: Impella CP in a Complex Pregnancy
Presenter
Neal Patel, DO, Broward Health Medical Center, Fort Lauderdale, FL
Neal Patel, DO1, Sarosh Tamboli, DO1, Kevin cortes-Gonzalez, MD1, Melissa Hidalgo, MD1, Sandi Dunn, MD2, Yash Raval, DO1, Yordanka Reyna, MD1 and Arnoux Blanchard, MD1, (1)Broward Health Medical Center, Fort Lauderdale, FL, (2)Broward General Medical Center, Lauderhill, FL
Title Two Hearts in Shock: Impella CP in a Complex Pregnancy Introduction Pregnancy induces profound hemodynamic changes that may unmask or exacerbate underlying cardiac pathology. We present a unique case of a young pregnant patient with a known atrial septal defect and prior ST-elevation myocardial infarction who presented with non-ST-elevation myocardial infarction in the setting of hypertensive emergency. The patient progressed to cardiogenic shock requiring Impella-assisted mechanical circulatory support. This case underscores the challenges of managing acute coronary syndromes and cardiogenic shock during pregnancy, particularly in patients with congenital and ischemic heart disease. It highlights the critical role of timely mechanical support to stabilize maternal hemodynamics while considering fetal outcomes. Clinical Case A 29-year-old G3P0 female with a 24-week IUP, with PMH of ASD, STEMI s/p 2 DES to the LCX, and marijuana usage presents due to abdominal pain. Found to have NSTEMI and severe MR with EF of 10% via TTE. The patient was promptly transferred to the cardiac ICU for further monitoring. She underwent prompt cardiac catheterizations. LHC revealed a chronic total occlusion of the LCX proximal to prior stenting, dilated LV with global hypokinesis, and EF of 10%. Impella CP was placed and set to P7 initially. Afterload reduction was begun as the patient’s MAP was in the 100s on admission and SVR>3000, using Bidil and Tridil infusion. The intensive care course was complicated by the patient experiencing frequent PVCs, so the decision was made to initiate beta blocker therapy, which the patient tolerated well. Initially, FICK calculations were incorrect due to the patient’s ASD. VBGs had to be drawn from the patient’s proximal cordis, and we subtracted “5” from the SVO2 to account for standard deviation from calculations. Three days following admission, the patient underwent spontaneous delivery of a nonviable fetus. Following the delivery, the patient’s MAP and SVR dramatically improved. Impella was removed on post-admission day 8, and she was successfully extubated on post-admission day 13. Repeat TTE post extubation revealed EF 25-30% along with severe MR. The patient endorsed a desire for subsequent pregnancies, for which she was educated on the contraindications given her severe cardiomyopathy. Discussion This case highlights the complexity of hypertensive cardiogenic shock characterized by low cardiac index and elevated systemic vascular resistance (SVR). Cocaine-induced catecholamine excess further increased SVR, compounding afterload and myocardial oxygen demand. The patient was treated with IV hydralazine. At 20 weeks, the gravid uterus requires over 10% of cardiac output, and inadequate uterine flow triggers sympathetic activation, further elevating SVR—a “uterine–placental steal” phenomenon. Fetal monitoring was essential despite a nonviable fetus, with multidisciplinary coordination to address risks of DIC and maternal compromise. The presence of an atrial septal defect became hemodynamically significant, altering Fick-based cardiac output and index calculations due to left-to-right shunting and affecting management decisions. In order to compensate we used a VBG sample from the SVC MVO2 and subtracted 5%, the expected decrease which occurs in the right atrium. This case underscores the need for vigilant hemodynamic assessment and multidisciplinary care in pregnancy-related hypertensive cardiogenic shock.