Case Review, COVID-19, Hemodynamics, Patient Management, AMI Cardiogenic Shock, Right Heart Failure
Impella RP® Treatment for a COVID-19 Patient in Cardiogenic Shock
Dimitri Karmpaliotis, MD, PhD, discusses the challenges of treating acute coronary syndromes in the COVID-19 era and presents a case of a COVID-positive patient with acute inferior STEMI managed with the Impella RP® heart pump. Dr. Karmpaliotis is an associate professor of medicine and director of CTO, complex and high-risk angioplasty at Columbia University.
Before presenting the patient case, Dr. Karmpaliotis briefly describes some of the “collateral damage” seen across the globe with regard to managing ACS during this COVID-19 pandemic. “We know very well that COVID patients can present with myocarditis, pericarditis, acute heart failure, arrhythmias, STEMI mimics, so the first decision, and probably the most difficult one, is when to take someone to the lab and what’s the suspicion, actually, that the patient is having an acute coronary syndrome.” He explains that many acute coronary syndromes are currently going undiagnosed and untreated or are presenting after significant time delays. He cites a study in which the time from symptom onset to first medical contact has increased to 318 minutes since January 2020 compared to about 80 to 90 minutes a year before.
Dr. Karmpaliotis presents a case of an active 65-year-old COVID-19 positive female presenting with diarrhea, generalized malaise, fever, and shortness of breath. Chest x-ray was unremarkable, and ECG was suggestive of an inferior ST-segment elevation myocardial infarction. Troponin, CK, and proBNP were high. Echo revealed right ventricular dysfunction. Hemodynamics were consistent with predominantly right-sided cardiogenic shock. An angiogram revealed a massive amount of clotting in the right coronary artery with all branches involved.
The team managing the case used manual aspiration thrombectomy to extract a significant amount of clot from the RCA and then did several rounds of mechanical aspiration with the Penumbra System until some branches were angiographically visible.
Dr. Karmpaliotis shows hemodynamic modeling of the right ventricle shutting down in a patient such as this with an RCA infarct with right-dominant circulation. He explains that the team determined that the patient was clearly in cardiogenic shock and initiated hemodynamic support with Impella RP. He then returns to the hemodynamic modeling to illustrate how the patient’s hemodynamics improved with right ventricular support.
“The patient immediately had an improvement after the insertion of the device,” he explains, adding, “It’s not only the hemodynamics, it’s the kidneys and it’s the total metabolic milieu that actually is improving in this patient.”
Emergency Use Authorization
The Impella RP is authorized for emergency use by healthcare providers (HCPs) in the hospital setting for providing temporary right ventricular support for up to 14 days in critical care patients with a body surface area ≥1.5 m2, for the treatment of acute right heart failure or decompensation caused by complications related to coronavirus disease 2019 (COVID‐19), including pulmonary embolism (PE). The Impella RP has not been cleared or approved for the treatment of acute right heart failure or decompensation caused by complications related to COVID-19.