Cardiology Fellow University of Oklahoma Oklahoma City, Oklahoma, United States
Disclosure(s):
Khushboo Agarwal, MD: No financial relationships to disclose
Background: Cardiogenic shock (CS) carries high mortality. The risk increases several-fold in pregnancy due to physiologic challenges of increased blood volume, demand for higher cardiac output, and vasodilation that can worsen vasoplegia. We report a rare case of cardiogenic shock and cardiac arrest in a pregnant woman, resuscitated with VA-ECMO.
Methods: A 31-year-old female at 24 weeks of gestation presented to an outside hospital with leg swelling. She was found to be in atrial tachyarrhythmia and treated with amiodarone, procainamide, and metoprolol. She quickly deteriorated, became hypotensive and hypoxemic, resulting in intubation. Vasopressors were started. Despite epinephrine, norepinephrine, and vasopressin, she was vasoplegic. Impella CP was then placed, and she was transferred to our facility. On arrival, Impella CP was at P3 due to significant suction alarms. The echocardiogram showed severe biventricular dysfunction. Immediate labs showed lactate 20, high-sensitivity troponin I 170, with severe acute kidney and liver injury. En route to the cardiac catheterization lab, she went into cardiac arrest (PEA rhythm) with 40 minutes of total attempted cardiopulmonary resuscitation (CPR) time with eventual replacement of Impella CP with peripheral VA-ECMO via femoral arterial and venous accesses during CPR. A distal perfusion catheter was placed in the right superficial femoral artery (FA) due to a noticeable cool extremity distally. Intraprocedural TEE showed no pulsatility with a closed aortic valve and left ventricular (LV) dilation. Impella CP was placed via left common FA; however, TEE further showed a suicide ventricle phenotype with continuous suction alarms. Impella CP had to be removed.
Outcome: IUFD was confirmed on ultrasound by a maternal-fetal medicine specialist. Expectant management with vaginal delivery pending maternal stabilization was pursued. Peri-procedurally, she required extensive blood product transfusions. Comprehensive physical exam, imaging, and lab evaluation ruled out vascular complications, intra-abdominal or vaginal bleeding, and disseminated intravascular coagulopathy. Over the next 12 hours, despite escalating inotropes, vasopressors, and volume management with continuous renal replacement therapy, the capillary wedge pressure remained elevated, and there was a loss of arterial pulsatility on VA-ECMO. An intra-aortic balloon pump (IABP) was placed for LV unloading. Thorough lab evaluation showed no evidence of infectious, thyroid-related, or other secondary etiologies for cardiomyopathy. She made a gradual cardiac recovery, and VA-ECMO was decannulated 7 days after placement. She then had recurrent episodes of long RP tachycardia managed with amiodarone. With hemodynamic stabilization, products of conception were delivered with spontaneous vaginal delivery 8 days following cardiac arrest. An electrophysiologic study was then pursued, which showed no inducible supraventricular tachycardia. IABP was removed 10 days following placement. Cardiac LV function recovered to 40-50% with good neurological and renal outcome. Cardiac MRI with and without contrast showed no evidence of infiltrative or inflammatory cardiomyopathy. The genetic test is pending.
Conclusion: Our case demonstrates that VA-ECMO can be successfully implemented for ECPR in pregnant patients with cardiogenic shock and cardiac arrest to improve survival. Rapid hemodynamic stabilization is crucial due to added risk of intrauterine fetal demise (IUFD) and associated complications. Multidisciplinary management, with rapid activation of shock team, is key.
