Trans-Caval Impella 5.0: A Bridge to Recovery in Peripartum Cardiomyopathy
Al-Darzi W, Michaels A, O'Neill W, and Williams CT. Trans-Caval Impella 5.0: A Bridge to Recovery in Peripartum Cardiomyopathy. J Card Fail 2019; 25(8):S147.
J Card Fail
Introduction: The incidence of peripartum cardiomyopathy (PPCMP) varies worldwide, the etiology is thought to be related to both environmental and genetic factors. The mortality rates are reported up to 16.7% and transplant rates up to 11%. The Interagency Registry for Mechanically Assisted Circulatory Support demonstrated improved myocardial recovery in PPCMP patients compared to non-PPCMP patients (6% vs. 1%) who required durable mechanical circulatory support devices (MCS). Our case demonstrates the use of trans-caval Impella 5.0 as a bridge to recovery in a PPCMP patient with cardiogenic shock post delivery. Clinical Presentation: 37-year-old woman with a history of PPCMP presented with progressive shortness of breath during the third trimester of pregnancy. She was found to have a decrease in left ventricular ejection fraction (LVEF) to 30-35% at 30 weeks gestation. Right heart catheterization showed RA 12 mmHg, PA 75/38 (50) mmHg, PCWP 30 mmHg, and CI 1.99 L/min/m2. She was transferred to Cardiac Intensive Care Unit (CICU) for invasive hemodynamic monitoring and tailored therapy. Nitroprusside was started with up titration of oral afterload reduction medications and continued intravenous diuresis. Due to preeclampsia, labor induction was initiated during week 34 of gestation. Secondary to multiple decelerations on fetal monitoring, an emergent primary C-section with bilateral tubal ligation was performed. Immediately after delivery, patient suffered hemodynamic collapse requiring emergent placement of a right femoral 2.5L Impella; noting small ilio-femoral arteries on angiography. There was no significant hemodynamic improvement (low cardiac index, elevated PA pressure, and progressive hypotension); patient was emergently upgraded to an Impella 5.0 via trans-caval approach under transesophageal echocardiogram guidance. Patient experienced cardiac arrest during procedure, with immediate ROSC. The Impella 5.0 placement was successful without complications and with improvement in hemodynamics (Improved CI from 1.3 to 1.6 L/min/m2, MAP from 55 to 88 mmHg, cardiac power output from 0.29 to 0.42 W), pH from 7.02 to 7.30. The 2.5L Impella removal was complicated by a right iliac artery rupture requiring a covered stent placement. CICU course was complicated by retroperitoneal hematoma, and acute renal failure requiring hemodialysis. Impella 5.0 was removed four days later; a 12/10 mm amplatz ductal occluder was used to close the trans-caval arteriotomy site. Hemodialysis was discontinued 12 days post-delivery and her LVEF improved to 40-45%. She was discharged to rehab and had significant improvement in her functional capacity on her 6-week follow up. Conclusion: Close monitoring and prompt action to escalate hemodynamic support, with temporary MCS to achieve better outcomes in cardiogenic shock is imperative. Trans-caval Impella 5.0 is a feasible alternative to extracorporeal membrane oxygenation and provides a high level of hemodynamic support which could bridge to myocardial recovery in PPCMP patients suffering from cardiogenic shock.