Change Of Heart: Interesting Case Of An Impella 5.5 Device Precipitating Electrical Storm And Right Ventricular Failure Treated With A Heart Transplant

Abstract

<h3>Introduction</h3> Electrical storm (ES) due to ventricular arrhythmias is a life-threatening condition requiring emergent medical and mechanical intervention. <h3>Case</h3> A 60-year-old man with a history of nonischemic cardiomyopathy and ventricular tachycardia (VT) on sotalol and remote implantable-cardioverter implantation (ICD), already listed for transplant was admitted for shortness of breath at rest and worsening lower extremity edema. Physical examination; jugular venous pressure (JVP) of 12cm H₂O, S3 gallop, bibasilar rales on chest auscultation, and bilateral lower extremity edema with warm extremities. A right heart catheterization revealed a cardiac index of 1.6 with elevated filling pressures and blood pressure of 80s/50s mmHg. EKG showed chronic left bundle branch block with 1^st degree AV block. TTE reported severe MR and LVEF of 15 %. Sotalol was discontinued and IV diuretics with vasopressor support were attempted, but recalcitrant cardiogenic shock (approximately18 hours later) required escalation to mechanical support via Impella 5.5. Subsequently, i.e., 36 hours after Impella placement, the patient had multiple episodes of incessant VT requiring more than 20 ICD shocks complicated by cardiovascular collapse <b>(Figure 1)</b>. The patient was emergently intubated, deeply sedated, and initiated on Amiodarone and Lidocaine infusions (after bolus). Bedside TTE revealed evidence of RV failure with uncertainty regarding the distal tip of the Impella. He underwent emergent veno-arterial extracorporeal membrane oxygenation support (ECMO); transplant listing was upgraded to UNOS status I and he received a heart transplant within 24 hours. Post-operatively patient had no recurrence of VT and he was transferred to a skilled nursing facility 45 days later. <h3>Discussion</h3> Our case met the criteria for a ventricular or electrical storm as defined by 3 or more sustained episodes of VT/VF or appropriate ICD shocks within 24 hours. The etiology was deemed to be the nidus of severe structural heart disease <b>(Figure 2)</b> exacerbated by discontinuation of anti-arrhythmic and possible provocation of the myocardium by Impella. Appropriate interventions including combination IV antiarrhythmic agents, deep sedation, and ECMO were temporary measures deemed insufficient to curb the ES; therefore, transplant was the only best option. <h3>Conclusion</h3> ES may require emergent medical and drastic surgical interventions including ECMO. This case represents a unique clinical situation where the patient was essentially (and ultimately) "treated" with a donor heart transplant.