Percutaneous biventricular Impella support in therapy-refractory cardiogenic shock Cheng-Ying Chiu, MD *, Robert Hättasch, MD, Damaris Praeger, MD, Fabian Knebel, MD, Karl Stangl, MD, Ivan Diaz Ramirez, MD, Henryk Dreger, MD Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Department of Cardiology and Angiology, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany A R T I C L E I N FO Article history: Received 17 December 2017 Accepted 17 March 2018 Available online Keywords: Cardiogenic shock Myocardial infarction Mechanical circulatory support Impella A B ST R AC T Introduction: Percutaneous mechanical circulatory support systems have increasingly been adopted as a bail out strategy in patients with cardiogenic shock. Since studies showed mostly mixed results, however, the use of support systems remains a case by case decision. Case: Here, we report on a case of therapy-refractory cardiogenic shock due to acute myocardial infarc- tion treated with percutaneous right and left ventricular assist devices (Impella RP and CP). Conclusion: Due to myocardial stunning, even patients with fulminant cardiogenic shock have the po- tential for full recovery. In the present case, we demonstrate the feasibility of biventricular Impella support in therapy-refractory cardiogenic shock facilitating bridge to recovery. © 2018 Elsevier Inc. All rights reserved. Introduction Cardiogenic shock due to acute myocardial infarction is associ- ated with high mortality and morbidity. 1,2 However, patients who survive cardiogenic shock have a good long-term outcome. Percu- taneous mechanical circulatory systems have thus increasingly been adopted as bail out strategy to improve short time survival, 3 of which extracorporeal life support (ECLS) and Impella pumps 4 (Abiomed, Danvers, MA, USA) are the most widespread. Acute right ventricular failure is a common and often fatal problem. Recent studies reported a beneficial role for a novel per- cutaneous right ventricular assist device (Impella RP) in the management of severe right ventricular failure. 5 Case report We describe a 67-year old Caucasian male who was admitted for inferior non-ST-segment-elevation myocardial infarction com- plicated by cardiogenic shock. Two vessel coronary artery disease with acute occlusion of the proximal right coronary artery (RCA) and a subtotal stenosis of the left anterior descending artery (LAD) were diagnosed. After recanalization of the RCA, the patient de- veloped bradycardia and severe low cardiac output, so that a temporary pacemaker and a percutaneous left ventricular assist device (Impella CP) were implanted. Echocardiography revealed acute heart failure with mildy reduced left ventricular ejection frac- tion and a severely impaired right ventricular function. Initial mixed venous oxygen saturation was 53%. Lactate was 3.44 mmol/l. Treat- ment with inotropes and vasoconstrictors as well as intravascular volume optimization failed to stabilize the patient leading to in- tubation (Figure 1A). Within 8 hours, the patient developed pulseless electrical activity (PEA), cardiopulmonary resuscitation was initi- ated and return of spontaneous circulation was achieved after 15 minutes. Despite optimal conventional therapy, acute right heart failure persisted. There was a decline in renal function and a sig- nificant increase in serum aminotransferases as a sign of hepatic congestion. NT-proBNP as one of the hallmark biomarkers in heart failure peaked at 6962 ng/l. Biventricular mechanical circulatory support was deemed necessary, so that a right ventricular assist device (Impella RP) was percutaneously placed 36 hours after ad- mission (Figure 1 A-C). Angioplasty of the LAD was performed in the same session. Hemodynamics improved immediately after support initiation leading to progressive organ function recovery, so that inotropic and vasoconstrictic support could be quickly weaned off. Mixed venous oxygen saturation improved to 70%. During mechanical circulatory support the patient was anticoagu- lated with unfractionated heparin to maintain an activated partial Conflict of interests: None. Funding: This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author. Fax: +49 30 450 7513 932. E-mail address: cheng-ying.chiu@charite.de (C.-Y. Chiu). 0147-9563/$ – see front matter © 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.hrtlng.2018.03.009 Heart & Lung ■■ (2018) ■■–■■ ARTICLE IN PRESS Contents lists available at ScienceDirect Heart & Lung journal homepage: www.heartandlung.com