Fellow- Advanced Heart Failure and Transplant Cardiology University of Iowa Hospitals and Clinics Iowa City, Iowa, United States
Background: Ventricular septal rupture (VSR) post-MI is a life-threatening condition with high mortality. Impella 5.5 provides crucial circulatory support, stabilizing patients for definitive surgery and improving outcomes. This case underscores Impella 5.5’s critical role in acute VSR management, ensuring stability and enabling life-saving intervention.
Methods: A 57-year-old female with a history of type 2 diabetes mellitus (T2DM) and hypertension presented to an outside hospital (OSH) emergency department in cardiogenic shock secondary to inferior wall ST-elevation myocardial infarction (STEMI). Emergent coronary angiography revealed a 100% occlusion of the right coronary artery (RCA). PCI of RCA was unsuccessful with no reflow phenomenon. Simultaneously, an infero-septal ventricular septal rupture (VSR) was identified, necessitating intra-aortic balloon pump (IABP) placement for hemodynamic stabilization. The patient was transferred to our facility for further management. On arrival, an Impella 5.5 was surgically placed via the right axillary artery to enhance circulatory support and mitigate left-to-right shunting caused by the VSR. At presentation, her lactic acid was 10 mmol/L, serum creatinine was 2.46 mg/dL, ALT and AST were 2,596 U/L and 4,307 U/L respectively. She had oliguric AKI requiring CRRT. She was noted to have a small left basal ganglia infarct with right sided weakness on 5th day of hospitalization which was conservatively managed. Qp/Qs ratios were monitored regularly while trying to keep them between 1-1.5 while awaiting definitive surgery.
Outcome: Definitive surgical VSR repair was performed successfully on 10th day of hospitalization. The Impella 5.5 device was explanted on post-operative day (POD) 8, and inotrope/vasopressor support was weaned by POD 11. Renal function and liver function returned to baseline eventually. She did not have any neurological deficits at discharge.
Conclusion: This case demonstrates the successful use of Impella 5.5 for left ventricular unloading in a patient with post-MI VSR in cardiogenic shock while reducing the shunt from LV to RV and thereby, augmenting cardiac output. Multidisciplinary approach integrating critical care, hemodynamic support, and timely surgical intervention is the key.
