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.