Abstract 17230: Acute Flash Pulmonary Edema Leads to a Spot Diagnosis of Acute Mitral Regurgitation From Impella LP 5 Induced Chordae Rupture: A Success Story!!

Abstract

Introduction: Impella devices are used as a temporary mechanical support for cardiogenic shock. Acute Mitral Regurgitation is a very rare complication after Impella placement. We present a case of sub-acute mitral regurgitation 2 days after removal of the Impala in a patient with cardiogenic shock after an acute anterior myocardial infarction. Case History: 37-year-old male with no significant past medical history was brought to the Emergency Room because of cardiac arrest at home. Patient had prolonged resuscitation time of about 45 minutes. After return of spontaneous circulation 12-lead electrocardiogram EKG showed typical anterior ST segment elevation MI. Right heart cath confirmed reflecting cardiogenic shock. Coronary angiogram revealed near ostial thrombotic occlusion of the LAD which was successfully treated with a drug-eluting stent. For severely reduced LV systolic function and severe cardiogenic shock Impella CP was inserted. Patient had an episode of cardiac arrest post procedure which was successfully resuscitated. On CCU day one we had a concern about positioning of Impella as it was considered to be under papillary muscle and under fluoroscopy and Echocardiogram guidance we attempted to reposition his Impella. Impella was removed on day 3. However all along we had difficulty adequately oxygenating him. His FiO2 was never below 50%. Eventually 2 days after Impella was removed (day 5 of admission) he had severe flash pulmonary edema. We could not oxygenate him on the ventilator on FiO2 of 100%. There was a concern of acute mitral regurgitation. This was confirmed by transthoracic and transesophageal echocardiogram showed flail anterior mitral leaflet P2 A3 likely chordae rupture. The patient was emergently taken to the operating room by cardiothoracic surgeon to undergo successful mitral valve replacement with a mechanical Saint Jude valve. From there patient slowly recovered. Patient was discharged home directly. Discussion: From the beginning it was felt that patient’s event is secondary to chordae rupture from the Impella device as the patient has otherwise demonstrated very good recovery post revascularization and therefore mechanical complication of MI would not be expected, also provided this was LAD territory along with the fact that the flail leaflet was not mediated by a papillary muscle rupture. Conclusion: It is pertinent to be very careful while repositioning Impella and one should always aim for a fluoroscopic guidance to reposition the device to avoid any damage to the surrounding structure.