Successful resuscitation of acute cardiogenic shock presenting as ventricular fibrillation via Bipella approach: a case report

Abstract

Background

The use of mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) complicated by biventricular failure is poorly discussed in the literature.

Case summary

We present successful treatment of a 52-year-old old man presenting with AMICS following cardiac arrest and prolonged CPR via a Bipella approach for biventricular support and restoration of haemodynamic stability.

Discussion

This case demonstrates the importance of understanding the role of MCS in the management of cardiogenic shock; the value of the cardiac power output and pulmonary artery pulsatility index as haemodynamic metrics to assess the cardiac function of a patient with cardiogenic shock; and the importance of a Bipella MCS approach in high inpatient morbidity and mortality AMICS with biventricular failure.

Learning points

• Mechanical circulatory support has an important role in the management of cardiogenic shock. A Bipella approach can help address high inpatient morbidity and mortality in acute myocardial infarction with cardiogenic shock followed by biventricular failure.

• The cardiac power output and pulmonary artery pulsatility index are valuable haemodynamic metrics in assessing cardiac function in cardiogenic shock.

Introduction

Early mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) has been shown to have benefits on survival rates and short-term outcomes compared to medical management alone.^1,2 We present a case of extremely high-risk AMICS presenting as out-of-hospital cardiac arrest successfully managed with a Bipella approach.

Timeline

Day 1	Out of hospital cardiac arrest with cardiogenic shock due to inferior ST-elevation myocardial infarction. The patient was intubated and on multiple pressors. Revascularization of the target lesion (proximal right coronary artery). Biventricular Impella placement followed by cooling protocol.
Day 2	The patient has been weaned off pressor. Echocardiogram revealed right ventricular failure and severely reduced left ventricular ejection fraction (LVEF) with inferior wall hypokinesis (30%).
Day 5	The patient was responsive and moving all extremities to command.
Day 7	LVEF improved to 50% and right ventricular function appeared normokinetic. Mechanical support has been removed without any complications.
Day 9	The patient has been extubated.
Day 19	The patient has been discharged in stable medical condition to inpatient cardiac rehabilitation.
2 months	Outpatient follow-up. The patient in good, fully functional condition.

Case presentation

A 52-year-old Caucasian man with an unremarkable past medical history presented to the emergency department via emergency medical services following a witnessed out-of-hospital ventricular fibrillation (VFib) cardiac arrest. He collapsed at home, in front of his friend who immediately contacted emergency medical services. First responders initiated cardiopulmonary resuscitation on arrival and the patient was shocked twice before the return of spontaneous circulation was observed. He was intubated and taken to the emergency department where he had recurrent VFib. The total time to the return of spontaneous circulation was 45 min. Vitals taken thereafter demonstrated a temperature of 33.9°C, heart rate of 82 b.p.m., and blood pressure of 98/77 mmHg via arterial line. His electrocardiogram revealed ST elevations in leads II, III, and aVF (Figure 1). Intravenous vasopressors (nor-epinephrine, epinephrine, and phenylephrine), amiodarone, magnesium, and lidocaine were administered. Physical exam of the intubated and sedated patient revealed coarse lung sounds bilaterally as well as hypoperfused and mottled extremities. The rest of the physical exam was normal. Though his presentation was most consistent with acute inferior ST-elevation myocardial infarction, differential diagnoses included massive pulmonary embolism and aortic dissection with coronary artery involvement. Initial labwork revealed a troponin I of 0.35 ng/mL, serum creatinine of 1.28 mg/dL, haemoglobin of 10.8 gm/dL, and lactate of >20 mmol/L (Table 1).

Figure 1.

Initial electrocardiogram upon arrival to the emergency department. Electrocardiogram demonstrating ST-elevations in leads II, III, aVF.

Table 1.

Patient haemodynamic metrics

	Normal range	Pre-LV Impella	Post-PCI/LV Impella	Post-RV Impella	24-h post- Bipella	48 h post- Bipella
Ao (S/D, mean) (mmHg)	(90–120)/(60–80), (65–95)	55/31, 39	66/40, 49	103/75, 88	138/87, 105	126/78, 86
LV (EDP) (mmHg)	<15	21	—	—	—	—
PCW mean (mmHg)	(6–15)	—	28	26	—	—
PA (S/D, mean) (mmHg)	(15–30)/(4–12), (9–19)	—	37/23, 20	36/18, 27	34/19, 24	32/18, 23
RA mean (mmHg)	(1–5)	—	24	23	16	14
C.O. (L/min)/C.I. (L/min/m2)	(4–8)/(2.6–4.2)	—	2.46/1.22	3.56/1.76	6.79/3.28	7.8/3.6
CPO/PAPI	>0.6/>0.9	—	0.33/0.58	0.69/0.78	1.58/0.93	1.49/1.0
Troponin I (ng/mL)	<0.23	0.35	>75	—	>75	62.3
Cr (mg/dL)	(0.67–1.15)	1.28	1.28	—	0.82	0.80
Hgb (gm/dL)	(14–18)	10.8	10.8	—	8.2	9.0
Lactate (mmol/L)	(0.7–2.7)	>20	>20	—	3.0	1.7

Haemodynamic metrics organized by stages of management.

He was taken for emergent cardiac catheterization. We began with unloading of the left ventricle with an Impella CP 4.0 device (ABIOMED, Danvers, MA, USA) through right femoral arterial access as directed by the National Cardiogenic Shock Initiative (NCSI) algorithm (Figure 2).² Coronary angiogram revealed an occluded right coronary artery (RCA) (Supplementary material online, Video S1), while the left coronary system showed mild disease confirming the diagnosis of AMICS. During insertion of the left ventricular (LV) Impella and coronary intervention, he had multiple episodes of ventricular tachycardia (VT)/VFib, so we continued cardiopulmonary resuscitation. He underwent successful percutaneous intervention to the RCA with mechanical thrombectomy and deployment of a Xience Sierra 3.0 × 23 mm drug-eluting stent (Abbott Vascular, Santa Clara, CA, USA) (Supplementary material online, Video S2). The stent was then optimized with a 3.0 × 15 mm non-compliant balloon.

Figure 2.

The National Cardiogenic Shock Algorithm. Algorithm used to guide the patient’s initial management and the decision to place the LV Impella device. Source: Ref.²

Focused transthoracic echocardiogram (TTE) revealed a moderately dilated and hypokinetic right ventricle as well as global LV hypokinesia, particularly at the level of the inferior wall. The ejection fraction (EF) was 30% (Supplementary material online, Video S3). Right heart catheterization was also performed via Swan-Ganz catheter, which revealed a cardiac power output (CPO) of 0.33 and a pulmonary artery pulsatility index (PAPI) of 0.6. We decided to place a right ventricular (RV) Impella device (ABIOMED, Danvers, MA, USA), following the NCSI algorithm (Figure 2). Once the right ventricle was supported with the RV Impella, his VFib stopped. A temporary transvenous pacemaker was placed prophylactically, because we believed the patient was at risk for significant bradyarrhythmia.

He was then transferred to the cardiac care unit (CCU) for hypothermia protocol and further management. He was weaned off vasopressor support over the next 24 h (Supplementary material online, Video S4). The NCSI was used to calculate CPO and PAPI (Figure 2).² These quantified his response to mechanical support and guided the de-escalation of both devices (Table 1).

On Day 5 of hospitalization, he was responsive to his name with purposeful movements. On Day 7, TTE demonstrated an improved EF of 45–50% with significantly improved RV contractility and wall motion (Supplementary material online, Video S5). His CPO improved to >0.6, and his PAPI improved to >0.9 with successful weaning of bilateral MCS. On Day 9, he was extubated. Post-extubation, his neurological status continued to improve. He retained long-term memory but had minor short-term memory deficits. On Day 19, he was discharged from the CCU and transferred to inpatient cardiac rehabilitation on guideline-directed medical therapy.

With occupational therapy, outpatient physical and cardiac rehabilitation, he eventually returned to his baseline. He continues to follow-up in our outpatient cardiology clinic.

Discussion

We report the successful treatment of AMICS with MCS utilizing a Bipella approach for out-of-hospital VFib cardiac arrest due to an acute inferior MI. We believe using two Impella catheters to be a unique approach to the treatment of AMICS with biventricular failure because it allows for rapid deployment of biventricular haemodynamic support.^2–4

Despite his AMICS presentation, our patient did not meet NCSI inclusion criteria for the use of MCS due to cardiopulmonary resuscitation lasting over 30 min. We intervened with MCS because of the patient’s young age, good baseline health and lack of known comorbidities in the setting of a reversible condition with preceding out-of-hospital return of spontaneous circulation.

The NCSI does not call for emergent echocardiographic evaluation of a patient’s haemodynamic status when meeting inclusion criteria. In these patients, catheterization lab activation, access and haemodynamic support are essential. Consequently, it is important to note that emergent echocardiography prior to LV Impella insertion, coronary angiography, and percutaneous intervention would not have changed our management.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is important to discuss in relation to our case. A limitation of microaxial pumps including Impella devices in AMICS is that they do not offer oxygen exchange or temperature control. VA ECMO reduces preload, increases end-organ perfusion and can be deployed rapidly.^5–7 A comparison of VA ECMO and RV Impella devices is presented in Table 2. Unfortunately, our institution does not have VA ECMO capabilities, so we followed the NCSI algorithm. We decided that if the patient’s haemodynamic status did not improve over 24–48 h following our initial intervention, we would transfer him to a tertiary centre with advanced heart failure care. If our Bipella approach had failed, the next step in escalation of care would have been the placement of a central biventricular assist device.

Table 2.

A comparison of RV Impella and VA ECMO characteristics

Device	Advantages	Disadvantages
RV Impella	Easy insertion Investigated in prospective clinical trials	Requires LV Impella for biventricular support Risk of emboli Immobility
VA ECMO	Bedside insertion Biventricular support Pulmonary support (gas exchange) Temperature control	Increasing LV afterload Risk of emboli Immobility

The patient’s recurrent VT/VFib was ongoing when he was brought the catheterization lab and continued while we inserted the LV Impella. We considered misplacement of the LV Impella or LV suction events as the cause for his ongoing VT/VFib, but there were no suction or placement signal alarms. TTE then demonstrated appropriate positioning of the LV Impella device and biventricular failure (Supplementary material online, Video S4). His haemodynamics were checked after LV Impella support and percutaneous coronary intervention as directed by the NCSI protocol which showed a CPO of 0.3 and PAPI of 0.6. Consequently, an RV Impella was inserted for RV MCS.^8,9

The recover right study and its inclusion criteria suggesting early RV support to improve outcomes is important in the discussion of our case. In this study, patients with RV failure after LV assist device implantation or RV failure after cardiotomy or MI were supported with an RV Impella device. It showed that in RV failure patients such as ours, RV Impella deployment had immediate haemodynamic benefit.¹⁰

In conclusion, AMICS with biventricular failure has high inpatient morbidity and mortality. The recognition of RV failure is essential as these patients can be successfully treated with MCS. Though the NCSI protocol excludes patients with cardiac arrest requiring prolonged cardiopulmonary resuscitation, our case demonstrates that MCS in these high-risk patients may still lead to an excellent outcome.

Lead author biography

Dominika M. Zoltowska is a specialist in Internal Medicine, and a second-year Cardiology Fellow at UF Health Jacksonville in Florida. She graduated from University of Gdansk in Poland, and completed her residency training at Western University of Michigan in Kalamazoo. She is interested in general cardiology with main interest in critical care of post-ACS patients.

Supplementary material

Supplementary material is available at European Heart Journal - Case Reports online.

Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data.

Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: None declared.

Funding: None declared.