Escalation Therapy, AMI Cardiogenic Shock, Surgical Applications

Lawrance: Biventricular Support for Myocarditis

 

Christopher Lawrance, MD, FACC, FACS, discusses a case featuring biventricular Impella® support in this Coronary Artery & Myocardial Protection (CAMP) Community Case Competition (COMP) presentation from October 2022. Dr. Lawrance is assistant professor of surgery at Southern Illinois University School of Medicine.

The case is an otherwise healthy, small, 35-year-old female (58 kg, 5’3”, BMI 22). She presents to the ED after 6 days of midsternal chest pain, fever, nausea, vomiting, and fatigue having had COVID infection one month prior. She is hypotensive when she arrives in the ED, presumed to have had sepsis, and admitted to the ICU, where she becomes progressively hypotensive. She has severe LV dysfunction (EF 10%), moderate RV dysfunction (PAPi 1.4), and is on high dose dual pressors with elevated lactate, acute kidney injury (AKI), and oliguria. She is sent to the cath lab for a right heart cath and deemed to be in SCAI shock class D.

The team places Impella CP® in the cath lab and decides to transfer her to a regional heart failure center; however, bad weather delays the transport. In the cath lab she continues to require high dose pressors and her lactate is rising. She’s become anuric. Cardiothoracic surgery is consulted and they perform subclavian placement of Impella 5.5®. Dr. Lawrance provides several pearls for subclavian Impella 5.5 placement, including tips for making the incision, use of a 10 mm rather than 8 mm graft, and strategies for minimizing bleeding.

The patient does not improve on Impella 5.5 support, and the team is getting suction alarms. TTE reveals severe RV dysfunction. They consider whether to add ECMO or an Impella RP® and decide that Impella RP is a better choice given her small vessels.

Upon initiating BIPELLA™ support, Dr. Lawrance emphasizes, “This is something I’ll never forget. She actually had an immediate return of urine within minutes. All the pressors were quickly discontinued. The lactate went from 7.4 to 2.4 over the next eight hours. And by the next morning her creatinine was 1.5 and her pH had normalized.” The transport team arrives and she is transferred to a regional heart failure center. A transplant evaluation is started but she has biventricular improvement and is discharged home.

Looking at pre- and post-procedural echocardiograms for this patient, Dr. Lawrance states, “This essentially looks like a new heart. Her EF was calculated out to be about 60, both on MRI and the TTE, and the cardiac MRI showed that she had findings consistent with resolving myocarditis.”

“I think having a heart team approach is key,” Dr. Lawrance concludes, “and I truly think that that’s why she’s alive today. At our facility we have an algorithm and we stuck to it, and it really benefited her.” He adds, “I don’t think an oxygenator is necessarily needed in the absence of lung disease. In her case we didn’t want to interfere with her peripheral vasculature and risk limb ischemia. So we wanted to keep things as simple as possible while still achieving the goal, which was biventricular support.”

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