Stepwise escalation of mechanical circulatory support from Impella 2.5 to CP to 5.5, and subsequent device exchange, successfully stabilized a 55-year-old man with cardiogenic shock.
Case Report (n=1)
This case highlights the importance of prompt recognition of mechanical circulatory support incompatibility or failure and the need for stepwise escalation of Impella support in complex high-risk PCI with cardiogenic shock.
Abstract 55 y/o male w/ PMH of prediabetes hyp,erlipidemia presented w/ acute chest pain starting 2 hours ago. No prior cardiac history cardiac history. Initial workup, HS Troponin 283, 882, peaking at 10,000. EKG showed Left anterior fascicular block, RBBB, and LA enlargement, no ST or T wave abnormalities. Given aspirin in ED and started on heparin drip and taken to cathlab. Imaging including CXR showed cardiomegaly, vascular congestion, interstitial opacities, B/L pleural effusions. Echo showed EF 25-30%, global LV hypokinesis, severely dilated LV, Grade 1 DD, moderate MR, mod TR, RVSP 62 mmHg, severe pulmonary HTN. Cath showed critical RCA stenosis and 100% ostial LAD occlusion with collaterals. LVEDP 50 mm Hg. Impella CP (2.5) was placed for LV support. Patient poor surgical candidate for CABG. Complex high-risk PCI planned. Patient developed worsening renal function, lactic acidosis, and hematuria secondary to hemolysis from Impella. Initially Impella CP 2.5 but inadequate flow, and patient still requiring a lot of pressors, with interval worsening renal function, lactic acidosis, concern for hemolysis with hematuria, thus escalated to Impella 5.5. There was interval improvement, however unable to increase power beyond P4 d/t suction alarms. Some concern for low flow as pt had received diuretics, thus gave fluids but no improvement. Cardiology, CTS, and Impella reps tried repositioning but no improvement, thus concern for device malfunction/obstruction, and decision for device exchange. Worsening cardiogenic shock prompted escalation to Impella 5.5. Flow later dropped to 1.5L/min despite repositioning attempts. revision procedure performed; old Impella 5.5 removed, new device placed with improved positioning confirmed by TEE. Post-revision, Impella flow stabilized at 3.5-4L/min at P6, later increased to 4-4.2L/min at P7. Renal function improved, UOP normalized, lactic acid downtrended, PA pressures improved. He underwent Impella protected PCI of LAD w/ rotablation and 3 overlapping stents, RCA with 2 overlapping stents. Important to be aware of stepwise escalation of care, and prompt recognition of MCS incompatibility/failure. Contributing factors include suboptimal anticoagulation, which predispose to device thrombosis. Warning signs were increasing purge pressures, ongoing suction alarms despite device manipulation, drop in flow despite higher P-levels, etc. Initial steps should include device trouble-shooting. Be vigilant of need for escalation of MCS accordingly, our patient had an Impella 2.5, then upgraded to Impella CP, then a 5.5, and then finally another 5.5. Patient improved over the next few weeks, was weaned off of MCS and is undergoing cardiac rehab. This abstract is funded by: None
Misbah et al. (Fri,) conducted a case report in Cardiogenic shock (n=1). Impella mechanical circulatory support was evaluated. Stepwise escalation of mechanical circulatory support from Impella 2.5 to CP to 5.5, and subsequent device exchange, successfully stabilized a 55-year-old man with cardiogenic shock.