Discussion
The mechanisms underlying the biventricular dysfunction following PCC
are not well established. Some proposed mechanisms include coronary
spasm with corresponding myocardial focal necrosis [2], direct
cellular toxicity by increasing intracellular calcium concentration
[3], damage induced by reactive oxygen species [4], and
myocardial stunning due to receptor desensitization or down-regulation
[5]. The ECMO is the largely used device for the management of CS,
but highly increases the afterload of the LV worsening the pulmonary
edema and triggering inflammatory reactions [6] whose combined
effects If not interrupted, can ultimately lead to a chronic dilated
cardiomyopathy. An effective strategy could be achieved by using an
axial flow pumps such as the Impella system that ensures unloading of
the LV throughout the cardiac cycle, decrease total mechanical work and
myocardial oxygen demand, while lowering WS and improving subendocardial
coronary blood flow. Hekimian et al reported several cases managed by
ECMO implantation [7], while Riester et al.[8described Impella device implantation as first choice. Our patient was
haemodinamically instable, so ECMO implantation was immediately
performed, rather than Impella implantation alone. Our case highlights
the importance of combined treatment in these patients to achieve an
early recovery. As reported, we had significant improvement in
ventricular EF after only 24 hours of MCS. Weaning from ECMO was started
after 48 hours, allowing ECMO removal within 4 days. The weaning from
the IMPELLA has been slightly postponed ensuring support in the early
stages of ECMO removal. After only 6 days from the implant, the IMPELLA
was removed and a complete recovery of both ventricles was observed.
These findings suggest that LV unloading by Impella support in addition
to V-A ECMO may be particularly effective in ensuring rapid recovery of
myocardial function, following catecholamine-mediated cardiomyopathy.
Conflict of interest: none declared.