Impella in Takotsubo syndrome complicated by left ventricular outflow tract obstruction and severe mitral regurgitation

Abstract

The treatment of cardiogenic shock in patients with Takotsubo syndrome (TTS) is challenging because it depends on the mechanisms leading to the haemodynamic instability. We report the case of a 70‐year‐old woman admitted for TTS complicated by cardiogenic shock. The early echocardiographic identification of left ventricular outflow tract obstruction (LVOTO) and severe mitral regurgitation (MR) prompted us to implant an Impella CP assist device as a bridge‐to‐recovery therapy. After device positioning, the haemodynamic status improved and LVOTO and severe MR disappeared. Because of the persistence of severe hypotension, the mechanical circulatory support was continued in intensive care unit and stopped only 5 days later, when intraventricular gradient spontaneously dropped. The patient was discharged after 1 week in stable conditions. Our case suggests that Impella circulating support may be a useful bridge‐to‐recovery therapeutic option in selected patients with cardiogenic shock due to TTS complicated by LVOTO and severe MR.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

“…It is therefore recommended to discontinue inotropic agents and administer fluids while monitoring the patient’s haemodynamic status. If TTE confirms the persistence of SAM with low cardiac output, current recommendations suggest the use of LV assist devices to improve cardiac output [ 3 , 10 , 17 , 54 ].

Figure 5 Two-dimensional transthoracic echocardiography, apical long-axis views, in patients with mitral regurgitation (MR) due to systolic anterior motion (SAM) of the mitral valve.

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Favorable Effects of Impella on Takotsubo Syndrome Complicated with Cardiogenic Shock

“…8,20,21) Although IABP effectively mitigates myocardial ischemia through a reduction in LV afterload and an increase in coronary flow by diastolic augmentation, enhancement in the cardiac index by IABP has been shown to be limited, 22) which is not sufficient for TTS with the hemodynamic collapse that needs full circulatory support. Additionally, a reduction of LV afterload by IABP may exaggerate or uncover LVOTO in TTS patients as previously reported, 14,23) which may occur if case 4 with LVOTO and case 2 with a reduction in colloid oncotic pressure due to hypoalbuminemia are treated via the IABP support. Hence, V-A ECMO has been shown to be effective for patients with cardiac arrest and those who need full circulatory support, and the use of V-A ECMO is increasing in TTS patients with CS.…”

“…However, the frequency of use of Impella support for TTS with CS is apparently less than that of IABP or VA-ECMO as shown by recent reports. 6,8) There are several single case reports regarding the use of Impella in TTS cases with hemodynamic deterioration, [9][10][11][12][13][14][15][16][17][18][19] but the hemodynamic effects of Impella support on TTS with CS were not characterized in detail in most case reports. Thus, we delineated clinical characteristics of four consecutive cases with TTS with CS who were successfully treated by Impella support and detailed hemodynamic responses to Impella support in TTS cases with CS.…”

Takotsubo Syndrome: Uncovering Myths and Misconceptions

“…The calcium sensitizer levosimendan has been suggested to present a therapeutic alternative in such cases [ 83 ]. Mechanical support with microaxial pumps (Impella) might also represent a therapeutic option for TTS patients with cardiogenic shock [ 84 , 85 ]. The effectiveness of mechanical support with Impella is unknown, and all available data is based on case reports, which report excellent outcomes but might suffer from inherent publication bias [ 86 ].…”