A 40-year-old male with familial dilated cardiomyopathy and Factor V Leiden mutation presented with SCAI stage C cardiogenic shock. Admitting hemodynamics were a right atrial pressure (RAP) of 9 mmHg, pulmonary arterial pressure (PAP) of 53/21 mmHg, pulmonary capillary wedge pressure (PCWP) of 24 mmHg, cardiac output (CO) of 2.5 L/min/m2, cardiac index (CI) of 1.5 L/min/m2, systemic vascular resistance (SVR) of 1926 dynes⋅sec⋅cm-5, and pulmonary vascular resistance (PVR) of 4 WU. The patient was started on milrinone with intra-aortic balloon pump (IABP) support. Hemodynamics improved, with a central venous pressure (CVP) of 9 mmHg, PAP 47/19 mmHg, PCWP 18 mmHg, CO 4.64 L/min/m2, CI 2.76 L/min/m2, SVR 977 dynes⋅sec⋅cm-5, and PVR 2 WU. Patient status was listed as 2 and subsequently underwent OHT with a 46-year-old female heart, with a donor-recipient predicted heart mass mismatch of -10% and total ischemic time of 238 minutes. The donor cause of death was intracranial hemorrhage, and the donor left ventricular ejection fraction (LVEF) was 55–60% with normal RV function and a septal wall thickness 0.8 cm. The transport of the donor organ was in a SherpaPak case with DelNido preservative solution.
Although no left ventricular (LV) dysfunction (LVD) was noted during the operation, the IABP was left in place per surgeon’s preference due to mild RVD, and the patient was on a medical therapy of epinephrine 0.02 mcg/kg/min, milrinone 0.5 mcg/kg/min and dobutamine 2.5 mcg/kg/min. Epinephrine was weaned within 24 hours, and a post-operative day (POD) 1 transthoracic echocardiogram (TTE) demonstrated normal LV function and mildly reduced RV function. The dobutamine dose was therefore increased to 5 mcg/kg/min and the IABP was removed. Hemodynamics subsequently deteriorated including a CVP of 22 mmHg, PAP of 37/21 mmHg, PCWP of 21 mmHg, as well as CO 3.14 L/min/m2, CI 1.84 L/min/m2, SVR 1535 dynes⋅sec⋅cm-5, PVR 1.7 WU) (Table 1). These changes necessitated increased dosage of dobutamine (7.5 mcg/kg/min) and epinephrine (0.03 mcg/kg/min), and initiation of inhaled nitric oxide (iNO). TTE continued to reveal normal LV function but moderately reduced RV function and dilatation (TAPSE 1.2 cm), and the intrinsic rhythm showed complete atrioventricular (AV) dissociation (Fig. 2). Despite aggressive diuresis, CVP remained > 20 mmHg with worsening cardiorenal syndrome requiring initiation on continuous renal replacement therapy (CRRT). Given the sinus node dysfunction and low mixed venous oxygen saturation, isoproterenol was added in addition to dobutamine, milrinone and epinephrine. However, the isoproterenol was not well tolerated by the patient, who developed nausea and vomiting side effects. The patient received immunosuppression (IS) therapy, including induction with thymoglobulin, and remained on triple IS therapy with mycophenolate mofetil, tacrolimus, and prednisone; endomyocardial biopsy revealed no rejection.
Table 1
Laboratory and hemodynamic parameters of the patient at different time intervals during the hospital stay.
| Pre-Transplant | Immediate Post- Transplant | POD 1 | POD 2 | Pre-Impella RP-Flex (POD 11) | Post Impella RP-Flex (POD 12) | Prior to Impella RP-Flex removal (POD 25) |
Hemoglobin (g/dL) | 12.8 | 10.6 | 10 | 9.4 | 7.4 | 7.8 | 8.1 |
Hematocrit (%) | 42.6 | 33.5 | 32.3 | 29 | 22.5 | 22.8 | 24.7 |
pH | 7.44 | 7.41 | 7.47 | 7.49 | 7.40 | 7.42 | 7.49 |
Creatinine (mG/dL) | 0.9 | 1.7 | 1.8 | 1.9 | 3.4 | 2.8 | 1.3 |
GFR (mL/Min/1.73 M2) | 111 | 60 | 55 | 45 | 31 | 43 | 87 |
AST (u/L) | 18 | 1509 | 1201 | 83 | 21 | 19 | 27 |
ALT (u/L) | 22 | 1388 | 2281 | 885 | 110 | 66 | 46 |
Bilirubin (mG/dL) | 0.9 | 3.2 | 3 | 1.4 | 0.7 | 0.6 | 0.6 |
Lactate (mmol/L) | 0.7 | 0.8 | 2.4 | 2.4 | 1.4 | 1.3 | 1.3 |
Inotropic Support | Milrinone 0.25 mcg/kg/min | Milrinone 0.5 mcg/kg/min Dobutamine 2.5 mcg/kg/min Epinephrine 0.02 mcg/kg/min | Milrinone 0.25 mcg/kg/min Dobutamine 5 mcg/kg/min | Milrinone 0.5 mcg/kg/min Dobutamine 7.5 mcg/kg/min Epinephrine 0.03 mcg/kg/min iNO 10ppm | Milrinone 0.5 mcg/kg/min Dobutamine 5 mcg/kg/min Epinephrine 0.02 mcg/kg/min | Milrinone 0.5 mcg/kg/min Dobutamine 5 mcg/kg/min | Milrinone 0.25 mcg/kg/min |
MCS | IABP 1:1 | IABP 1:1 | | | | Impella RP-Flex at p7 | Impella RP-Flex weaning |
SvO2% | 70 | 71 | 50 | 63 | 50 | 71 | 67 |
CVP (mmHg) | 9 | 9 | 22 | 7 | 24 | 10 | 6 |
PAP (mmHg) | 47/19 | 25/9 | 37/21 | 26/9 | 40/27 | 32/18 | 26/15 |
PCWP (mmHg) | 18 | 9 | 21 | 9 | 23 | 18 | 15 |
CO (L/min) | 4.64 | 5.42 | 3.14 | 5.02 | 5.5 | 7.98 | 8.62 |
CI (L/min/m2) | 2.76 | 3.17 | 1.84 | 2.94 | 2.5 | 4.53 | 5.1 |
SVR (dynes⋅sec⋅cm− 5) | 977 | 1053 | 1535 | 1130 | 1169 | 617 | 612 |
PVR (WU) | 2 | 1 | 1.7 | 1.1 | 0.8 | 0.8 | 0.8 |
POD, postoperative day; GFR, glomerular filtration rate; AST, aspartate aminotransferase; ALT, alanine transaminase; MCS, mechanical circulatory support; IABP, intra-aortic balloon pump; SvO2, venous oxygen saturation; CVP, central venous pressure; PAP, pulmonary arterial pressure; PCWP, pulmonary capillary wedge pressure; CO, cardiac output; CI, cardiac index; SVR, systemic vascular resistance; PVR, pulmonary vascular resistance |
Despite three inotropic agents (milrinone, dobutamine and epinephrine), iNO and CRRT, Impella RP Flex was placed via the right internal jugular vein on post-operative day (POD) 12 due to refractory right-heart failure. Impella RP Flex was chosen as a mechanical RV support device given its ease of insertion, ability to facilitate mobility and physical therpay in a recovering transplant patient. The patient was also on systemic anticoagulation with heparin with a goal activated clotting time (ACT) of 180–200 sec, and a higher-than-typical goal ACT (160–180) was chosen due to the patient’s history of hypercoagulable Leiden V mutation. The implantation procedure was well tolerated, with the patient ambulatory the following day and able to continue physical therapy with the device in place (Fig. 3). Epinephrine and dobutamine were slowly weaned, and on POD 25, the Impella RP flex was removed. iNO and milrinone were subsequently weaned and the patient achieved native renal recovery and no longer required CRRT. Intrinsic rhythm improved to sinus rhythm (Fig. 2), and the patient was ultimately discharged on POD 50 without inotropes and with normal kidney function. Pre-discharge TTE revealed a normal LVEF of 60–65% and low-normal RV function with normal cavity size and TAPSE 1.6 cm.