We report a case of a young woman with cardiogenic shock following severe coronary artery disease. Assumingly, the well-balanced combination of different options for ventricular support in early response to the individual course of the patient guided by an interdisciplinary team was the key to successful management of this extraordinary case (Table 1;Figure 1).
Mortality in cardiogenic shock is about 40% [2]. In patients with acute heart failure and hemodynamic instability (INTERMACS level 1 und 2) short-term mechanical circulatory support (MCS) may be used to stabilize the patient, to gain time for further decisions on definitive therapy [1]. In a cohort of patients with cardiogenic shock in myocardial infarction Thiele identified a subgroup of 15-25 % that will possibly survive by a MCS device, while 50-60 % will survive without a MCS and 25-35 % will die with or without a MCS (e.g. brain death, sepsis) [11].
Different options for MCS are currently available. However, for a positive outcome the right choice of the device as well as proper timing for initiation as well as for escalation or de-escalation appear to be of paramount importance [5]. VA-ECMO provides complete cardiopulmonary support and is widely used in cardiothoracic surgery [5]. It is independent from the patient´s rhythm and even in malignant arrhythmias will show no flow alterations [2]. However, VA-ECMO in it’s peripheral (femoral) form may cause LV distension due to high afterload. LV distention in turn can exacerbate myocardial ischemia, trigger arrhythmias and may lead to pulmonary edema. Truby found 7% of patients to have a high and 22% to have considerable LV distension on VA-ECMO [12]. In the literature there are suggestions for LV unloading not only by inotropic support, but also by intra-aortic balloon pump (IABP), Impella and other surgical techniques [13].
A retrospective study by Pappalardo et al. showed a significantly lower in-hospital mortality (40% vs. 74%) and a higher rate of a successful bridging to long-term strategies or recovery (62% vs. 30%) in patients treated with concomitant VA-ECMO and Impella® as compared to treatment with VA-ECMO alone [6]. In the largest US-based retrospective study, VA-ECMO (n=36) vs. ECPELLA (n=30) in patients with refractory cardiogenic shock, the combined treatment with Impella® and VA-ECMO was associated with lower all-cause 30-day mortality, lower need for inotropic support and a comparable safety profile [7].
A metanalysis of 17 observational studies published in 2019 showed a lower mortality with different forms of LV unloading (54% vs. 65%), but in patients with additional Impella markedly more hemolysis was noted [14]. Therefore, the combination of VA-ECMO and Impella should be restricted to a limited period of time.
LV and RV Impella (BiPELLA) could be indicated in patients with a biventricular failure and contraindications to VA-ECMO. A simultaneous initiation of support with BiPELLA can be associated with improved survival outcomes [8]. A further research is required to provide evidence of the effectiveness of BiPELLA and an implantation of BiPELLA on top of a VA-ECMO.
The implantation of a temporary extracorporeal left ventricular assist device (e.g. Rotaflow®) can bridge over a longer time period to a permanent device in unclear conditions. In the literature one case with a bridge to recovery is reported, in our case it was a bridge-to-bridge concept [15]. The most frequent complications are bleeding, thromboembolism and vascular complications, followed by neurological and respiratory problems [3].
A multidisciplinary heart-team (including cardiothoracic surgeons, cardiologists, anesthesiologists, intensive care specialists, and perfusionists) should join expertise to select and rapidly intervene on patients with severe cardiogenic shock [9,10]. Tehrani et al suggested the implementation of a multidisciplinary standardized team approach [10]. In their observational study a standardized team approach could significantly increase 30-day MCS survival from 47 to 77% [10]. We highly recommend the additional implementation of psychological and psychosocial support for the patient, the family and the team as well as access to ethical advice and palliative care as proposed in the European Guidelines and in the scientific statement of the American Heart Association [1].
In conclusion, the addition of LV Impella (CP®) implantation and RV support by Impella (RP®) (BiPella) on top of VA-ECMO may support survival outcomes in refractory cardiogenic shock. In uncertain situations a paracorporal (short-term) LVAD (Rotaflow) can be used as a ´second bridge´ to long-term mechanical support with LVAD.