Refractory Cardiogenic Shock in a Young Male: Barriers to Urgent Heart Transplant

Abstract

A 26-year-old male presented with chest pain and an acute anterior STEMI. His past history was notable for Crohn's disease on adalimumab, as well as metallic mitral and aortic valves following Candida parapsilosis endocarditis on presumed rheumatic valves. Angiography revealed a saddle embolus appearance at the proximal LAD/first diagonal bifurcation, treated with two drug eluting stents. He subsequently became febrile with a suspicious echodensity seen on the mitral annulus; the embolus therefore was thought either due to culture negative recurrent prosthetic endocarditis or thrombus in the setting of a subtherapeutic INR(1.6). Empiric antibiotics were given as well as heparin anticoagulation. His clinical course was turbulent, with refractory cardiogenic shock (ejection fraction 12%) dependent on multiple inotropes and intermittent dialysis. Concerns were raised regarding the severity of his Crohn's given intercurrent gastrointestinal bleeding; this along with suspected infection of a femoral pseudoaneurysm delayed initial transplant referral. After 4 weeks however he developed acutely worsening cardiogenic shock and was transferred to a transplant centre on VA-ECMO. Unfortunately despite urgent national listing, no body size and blood group matched donor could be found and he was delisted upon development of disseminated pulmonary aspergillosis in week 5 of VA-ECMO support. Soon after he suffered multiple embolic strokes and was palliated before passing away. Mortality for patients in refractory cardiogenic shock remains high despite modern supportive care. Early discussion with a transplant centre regarding suitability and barriers to transplant is essential; notably intra-cardiac infection does not preclude heart transplant consideration.