Cardiology Fellow Houston Methodist Hospital-DeBakey Heart & Vascular Institute Houston, Texas, United States
Disclosure(s):
Saliha Erdem, MD: No financial relationships to disclose
Background: Acute right ventricular (RV) failure following inferior ST-elevation myocardial infarction (STEMI) can rapidly progress to refractory cardiogenic shock. Determining when to escalate from medical therapy to mechanical circulatory support (MCS), and whether isolated RV support is sufficient, remains clinically challenging.
Methods: The patient developed refractory shock requiring multiple vasopressors and inotropes and underwent emergent coronary angiography demonstrating acute RCA stent thrombosis. Despite preserved left ventricular systolic function, biventricular MCS with Impella CP and Impella RP was initiated at an outside hospital. Following transfer, invasive hemodynamics and echocardiography demonstrated predominant RV failure. Left-sided support was successfully discontinued early without hemodynamic compromise, while isolated RV support was continued and subsequently weaned. RV function normalized, vasopressors were discontinued, and the patient survived the acute shock episode, though hospitalization was complicated by prolonged ventilation and encephalopathy.
Outcome: The patient developed refractory shock requiring multiple vasopressors and inotropes and underwent emergent coronary angiography demonstrating acute RCA stent thrombosis. Despite preserved left ventricular systolic function, biventricular MCS with Impella CP and Impella RP was initiated at an outside hospital. Following transfer, invasive hemodynamics and echocardiography demonstrated predominant RV failure. Left-sided support was successfully discontinued early without hemodynamic compromise, while isolated RV support was continued and subsequently weaned. RV function normalized, vasopressors were discontinued, and the patient survived the acute shock episode, though hospitalization was complicated by prolonged ventilation and encephalopathy.
Conclusion: In acute RV failure complicating inferior STEMI, early escalation to MCS may be life-saving when medical therapy fails. Careful hemodynamic and imaging assessment is critical to identify patients in whom isolated RV support may be sufficient, potentially avoiding unnecessary left ventricular mechanical support and its associated risks.
