Lights and shadows of the microcoaxial pump device in a unique setting: cardiogenic shock due to acute myocardial infarction in patient with unknown hypertrophic cardiomyopathy

Abstract Cardiogenic shock remains the leading cause of death in patients with acute myocardial infarction (AMICS). The IntraAortic Balloon Pump (IABP) has been the device of first choice for these patients for years, but it has not shown a mortality benefit over optimal medical therapy. The Impella (AbioMed, Danvers, Massachusetts) is an alternative circulatory support system that produces cardiac output appropriate for the needs of the patient. A 59–year–old mailman suddenly lost consciousness during his work. Basic life support was administered, and ROSC was achieved after a single effective defibrillator discharge. When the ambulance arrived, the patient presented conscious but complained of oppressive chest pain, with soreness in his left arm and head. EKG showed an ST elevation in aVR and aVL and a right bandle branch block (Fig 1). Aspirin, Heparin, and opioids were administered. During the transport, hemodynamic parameters appeared to deteriorate towards cardiogenic shock. Coronary angiography showed a total occlusion of the left main. Cangrelor was started promptly. Hemodynamic conditions dictated the application of a mechanical circulatory support device (MCSD), so IABP was applied. Primary angioplasty was performed with restoration of TIMI 3 flow. A 3.50 x 23 mm everolimus–eluting stent was implanted with a good result. Norepinephrine was ineffective in achieving satisfactory hemodynamic status with systemic arterial pressure below 50 mmHg. After volemic restoration, neither IABP nor the vasopressor could interrupt the spiral of cardiogenic shock. A coaxial pump, i.e. the Impella CP, was applied via left arterial femoral access. Despite the precise placement of this device, the parameters suggested a poor suction capacity from the pump–inlet into the left ventricle (LV) to systemic circulation in aorta. Meanwhile, echocardiogram revealed an unknown and severe hypertrophic cardiomyopathy that did not allow a proper functioning of the Impella CP device (Fig. 2). When a temporary pacemaker was applied due to reperfusion bradycardia, there were a better LV diastolic filling and Impella functioning due to right pacing. The patient was transferred to the intensive care unit, Impella was removed after 3 days, he was extubated within two weeks, no brain damage was reported but he is still hospitalised after a concomitant urinary infection, with predictable low ejection fraction (around 30%). We‘ll see: luckily, slow improvement, it is still an improvement!