Bridge to Recovery with Early Mobilisation: The Impella Device via Axillary Artery in Lupus-Associated Acute Cardiomyopathy

Abstract

A previously healthy 33-year-old woman of South East Asian descent presented with myalgia and petechial leg rash. Acute cardiogenic shock, lactic acidosis, and oligoanuria evolved rapidly over 24 hours, with hypotension refractory to inotropes. Echocardiography demonstrated severe global left ventricular dysfunction with an ejection fraction of 10–15%. She was commenced on femoral veno-arterial extracorporal membrane oxygenation and renal replacement therapy. An endomyocardial biopsy was non–diagnostic, but an anti-dsDNA titre of >800, positive Smith antigen, and marked complement consumption confirmed the diagnosis of systemic lupus erythematosus-associated acute cardiomyopathy, and high-dose corticosteroids were initiated. After 10 days on extracorporal membrane oxygenation, as a potential bridge to transplantation, she was transitioned to an Impella CP device via the right axillary artery to support the left ventricle, allowing her to begin mobilisation. The Impella device remained in situ for 13 days with gradual weaning of inotropes while she started weight-bearing exercises with assistance. Her left ventricular ejection fraction improved to 30% on repeat echocardiogram prior to device removal, and to low-normal on magnetic resonance imaging subsequently. This case highlighted the utility of the Impella device to support the failing left ventricle while facilitating early mobilisation in patients with acute cardiomyopathy of reversible aetiology requiring a protracted course of mechanical support. To our knowledge, this was the first case of an Impella device inserted via the axillary route in Australia. The axillary approach offers a mobilisation friendly, minimally invasive option in the expanding artillery of short-term mechanical circulatory support, either as a bridge to myocardial recovery or cardiac transplant.