Use of Impella 2.5 and Veno-Arterial Extracorporeal Life Support (VA ECLS) in severe cardiogenic shock secondary to refractory arrhythmia.
Patients with cardiogenic shock secondary to refractory ventricular tachycardia (VT) have a poor outcome. Catheter ablation therapy is often Indicated but may be prohibited by ongoing haemodynamic instability1, 2, 3, 4, 5.
A 46-year-old female patient presented with cardiogenic shock secondary to recurrent episodes of polymorphic VT and ventricular fibrillation (VF). Three years previously, she had presented with atrial fibrillation which progressed to polymorphic VT after administration of metoprolol. Following successful cardioversion, diagnostic cardiac investigations were reported as normal. An implantable cardioverter defibrillator (ICD) was inserted at that time.
On this admission, the patient developed cardiogenic shock secondary to recurrent episodes of VT/VF. Multiple ICD and external shocks were delivered. On interrogation of the ICD, 60 shocks had been delivered in the previous 10 hours.
The patients required tracheal intubation, mechanical ventilation, high dose vasopressor infusions and prolonged periods of resuscitation with a mechanical chest compression device (Lucas, Physio-Control). Multiple antiarrhythmic agents, including flecainide were administered. Mechanical circulatory support was achieved with a catheter-based temporary ventricular assist device (Impella 2.5, Abiomed) inserted into the left ventricle (LV) from the right femoral artery during active chest compressions. The number of episodes of VT/VF requiring defibrillation decreased over the following 12 hours, however, the patient remained in cardiogenic shock with persistently high plasma lactate concentration and developed anuric renal failure.
The Mater ECLS service was contacted and a decision was made to send an ECLS retrieval team to the referral hospital to initiate peripheral VA ECLS (Cardiohelp, Maquet). Eighteen hours after her presentation, a 25F ECLS access cannula was advanced into the right atrium from the right femoral vein. A 17F ECLS return cannula and an 8F backflow cannula could not be placed percutaneously and required a surgical cut down on the left femoral artery. Satisfactory ECLS blood flow was achieved and a decision was made to removed the Impella device and surgically repair the right femoral artery prior to transfer back to the Mater Hospital. There was a rapid improvement in the shock state and the vasoactive infusions were weaned.
Catheter ablation therapy
On stopping sedation, the patient followed simple commands and there was a return of native urine output. While still on VA ECLS and after a prolonged session in the electrophysiology laboratory, an arrhythmogenic focus was located and successfully ablated. VA ECLS was weaned on day 7 and the left femoral artery was surgically repaired. The patient made a complete neurological recovery and no further episodes of VT/VF were recorded. The patient was discharged home and resumed full employment 3 months after presentation.
Several authors have described the simultaneous use of the Impella device and peripheral VA ECLS in patients with cardiogenic shock6, 7. The Impella may decrease the high LV afterload associated with peripheral VA ECLS7. Despite this shortcoming, peripheral VA ECLS provided prolonged haemodynamic stability for this patient allowing sufficient time to investigate and treat the cause of the refractory dysrhythmia.
Use of the Impella 2.5 device either alone or combined with peripheral VA ECLS should be considered early in cardiogenic shock patients with potentially reversible, recurrent ventricular tachycardia. A sufficient period of haemodynamic stability has to be provided to locate and treat the cause of the arrhythmia. The improved haemodynamic support is also likely to reduce the chances of coronary or cerebral ischaemic injury.
1. Bunch, T.J., Mahapatra, S., Madhu Reddy, Y. & Lakkireddy, D. The role of percutaneous left ventricular assist devices during ventricular tachycardia ablation. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 14 Suppl 2, ii26-ii32 (2012).
2. Dixit, S. & Callans, D.J. Role of contact and noncontact mapping in the curative ablation of tachyarrhythmias. Current opinion in cardiology 17, 65-72 (2002).
3. Lu, F. et al. Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support. International journal of cardiology 168, 3859-3865 (2013).
4. Marchlinski, F.E., Callans, D.J., Gottlieb, C.D. & Zado, E. Linear Ablation Lesions for Control of Unmappable Ventricular Tachycardia in Patients With Ischemic and Nonischemic Cardiomyopathy. Circulation 101, 1288-1296 (2000).
5. Zeppenfeld, K. & Stevenson, W.G. Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease. Pacing and Clinical Electrophysiology 31, 358-374 (2008).
6. Gaudard, P. et al. Management and outcome of patients supported with Impella 5.0 for refractory cardiogenic shock. Critical care (London, England) 19, 363 (2015).
7. Pieri, M. et al. The contemporary role of Impella in a comprehensive mechanical circulatory support program: a single institutional experience. BMC Cardiovascular Disorders 15, 126 (2015).