Safety And Efficacy Of Impella RP Support For Acute Right Ventricular Failure Complicated By Cardiogenic Shock: Post Market Approval SubAnalysis Of The CVAD Registry

Document Type

Conference Proceeding

Publication Date

1-1-2024

Publication Title

J Card Fail

Abstract

INTRODUCTION: Takotsubo cardiomyopathy (TTC) is characterized by reversible apical ballooning without severe coronary artery disease. TTC with left ventricular outflow tract obstruction (LVOTO) is classically managed with phenylephrine, beta-blockers, and fluid resuscitation, avoiding inotropic agents due to concern for worsening obstruction. Management is further complicated in the setting of hemodynamically significant mitral regurgitation (MR), where fluid resuscitation may worsen cardiopulmonary status. In such cases, depending on the patient's clinical status and hemodynamics, they may either benefit from short-term mechanical circulatory support (MCS), such as an intra-aortic balloon pump, or may have LVOTO exacerbated. We describe a case of TTC with LVOTO and severe MR successfully managed with pharmacologic therapy avoiding mechanical and inotropic support. CASE: A 70-year-old female presented with acute onset of dyspnea and presyncope during strenuous exercise. On presentation, she was hypotensive (76/52 mmHg), tachypneic (29 breaths/min), and hypoxic requiring a high-flow nasal cannula at 40L/min at 100% FiO2. Initial laboratory tests included high-sensitivity troponin T 334 ng/L, proBNP 566 pg/mL, and lactic acid 2.5 mmol/L. Electrocardiogram showed normal sinus rhythm, right bundle branch block, and non-specific ST abnormalities in lateral leads. Initial bedside echocardiogram demonstrated left ventricular (LV) apical akinesis with a hyperdynamic base with an ejection fraction (EF) of <30% concerning TTC. Color doppler showed severe posteriorly directed MR, and pulse-wave doppler at the LV outflow tract showed a late peaking jet with a peak gradient of 46.4 mmHg. Left-heart catheterization showed minimal coronary artery obstruction. Right-heart catheterization showed elevated RAP 13 mmHg, PAP 57/24 mmHg (mean 39 mmHg), and PCWP 29 mmHg with Fick calculated CO 4.48 L/min and CI 2.5L/min/m 2 . Phenylephrine, esmolol, and IV furosemide were initiated. Short-term MCS was deferred, and she was successfully weaned from vasopressor within three days. Follow-up echocardiogram seven days following admission showed recovered EF of 70% and resolution of LVOTO. CONCLUSION: Our case represents a challenging scenario of TTC with LVOTO in a patient with severe MR. In cases with mitral insufficiency, up to 36% of patients may require an IABP; however, its use is controversial in LVOTO due to its counter-pulsation effect which reduces afterload consequently increasing the pressure gradient between the LV and aorta. Our patient was successfully managed by a pharmacological approach, including Esmolol as a superior beta-blocker as it is a beta-one cardio-selective drug with a short half-life. It allows accurate titration to help optimize heart rate and cardiac filling times. Despite the current recommendations for IV fluids in patients with TTC with LVOTO, in the setting of severe MR, an RHC to assess hemodynamics may be critical in guiding therapy. This approach can decrease the need for short-term MCS and provide an alternative to patients who defer invasive therapies.

Volume

30

Issue

1

First Page

269

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