A Case of Extended Mechanical Circulatory Support with Impella 5.0 in a Patient with Cardiogenic Shock Secondary to Left Ventricular Aneurysm

Introduction Data from the Nationwide Inpatient Sample (NIS) indicate that the incidence of cardiogenic shock (CS) has increased in the last two decades. Despite recent advances in mechanical circulatory support (MCS), CS-attributable morbidity remains high, portending a poor prognosis for patients at risk of developing CS acutely in the setting of percutaneous coronary intervention (PCI), cardiac surgery, or acute decompensated heart failure (ADHF). Herein, we describe the case of a patient maintained on 18 days of Impella 5.0 MCS, following ADHF and CS in the setting of a large LV aneurysm. Case Description A 66 year-old male patient with a history of ischemic cardiomyopathy with two-vessel coronary artery bypass grafts presented to an outside hospital for an episode of ADHF. Left heart catheterization performed at the outside hospital showed left anterior descending (LAD) and left circumflex (LCx) artery disease with patent grafts. There was severe disease of the mid-right coronary artery (RCA) which was treated with PCI. One week following intervention, the patient became acutely hypotensive and hypoxemic at rest. Echocardiography at that time showed possible LV aneurysm, though contained rupture of the LV free wall could not be excluded. The patient was intubated and transferred to our hospital for further management. Upon arrival to our institution, imaging was performed, which confirmed the presence of a large anterolateral/inferolateral LV aneurysm with severely reduced ejection fraction (EF) to 30% (Figure). The patient was noted to be in multiorgan failure secondary to CS, and the decision was made to place an Impella 5.0 as a bridge to decision. The patient was maintained on Impella 5.0 for hemodynamic support for 18 days post-operatively, until, on hospital day 32, the patient expired due to septic shock from C. difficile colitis. Conclusion Impella 5.0 is currently indicated for use in patients with cardiogenic shock and for high risk PCI. Scant literature exists to support the use of Impella as a bridge to decision or namely bridge to permanent left ventricular assist device or bridge to heart transplant; in these investigations, mean duration of support ranges from approximately 0 to 13 days. The utility of Impella has not been studied in patients with LV aneurysm. Our case suggests that the Impella 5.0 can be used in patients with LV aneurysm for hemodynamic support for an extended clinical course.