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Left ventricular (LV) unloading has been associated with improved survival in patients treated with venoarterial extracorporeal membrane oxygenation. This case describes a patient with a COVID-19 infection who subsequently developed non-ischemic cardiomyopathy with an LV ejection fraction of 10% to 15% (baseline echocardiography). He did poorly in the outpatient setting and was admitted to an outside hospital with heart failure symptoms and was subsequently transferred to our hospital for escalation of care and consideration of advanced heart failure therapies. This clinical image and related video series help to visually demonstrate the effect of LV unloading in a 30-year-old male with a history of COVID-19 myocarditis.

A 65-year-old female was transferred with myocardial infarction, three-vessel coronary artery disease, cardiogenic shock and an intraaortic balloon pump. Given persistent shock, mechanical circulatory support (MCS) was upgraded using a left ventricular hemodynamic support device (Impella CP). The patient was monitored in the catheterization laboratory and serial hemodynamic measures were obtained. Initial hemodynamics showed relative improvement; however, serial assessments demonstrated worsening hemodynamics secondary to right ventricular failure, ultimately requiring a right ventricular hemodynamic support device. The case highlights the rapid changes that can occur with mechanical circulatory support devices and demonstrates the importance of obtaining serial hemodynamics in the cardiac catheterization laboratory., (© 2021 Wiley Periodicals LLC.)

The outcomes for patients transferred with cardiogenic shock and later treated with revascularization and Impella support have not previously been studied. To evaluate these outcomes, patients in cardiogenic shock were recruited from the catheter-based ventricular assist device registry, a prospective registry enrolling patients who underwent percutaneous coronary intervention with hemodynamic support using Impella 2.5 or CP. Analysis was performed on subgroups of patients who were characterized as those directly admitted to a tertiary care hospital (direct), or those transferred from an outside hospital (transfer). Patients who were transferred with acute myocardial infarction with cardiogenic shock (AMICS) more often presented in shock were in shock longer than 24 hours, and were more likely to be on intra-aortic balloon pump but were less likely to sustain cardiac arrest. The number of pressors, EF, diseased, and treated vessels were similar between the 2 groups. Despite baseline differences, the mortality was similar in the transfer versus direct patients (47.0% vs 53.5% p = 0.19). In a multivariate model, the factors independently associated with 30-day mortality in AMICS treated with revascularization and Impella support were cardiopulmonary resuscitation (CPR) (p <0.01), age (p <0.01), and ST-segment elevation myocardial infarction (STEMI) (p = 0.02). Whether the patient was transferred or directly admittedly with AMICS was not an independent predictor of death. In conclusion, these findings suggest that considerations should be given to transfer patients with AMICS to allow them to be treated in a contemporary manner., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Currently, there are no data on the use of mechanical circulatory support (MCS) in patients without severely depressed left ventricular ejection fraction (LVEF) during high-risk percutaneous coronary intervention (PCI). We analyzed data from the global catheter-based ventricular assist device (cVAD) registry on the clinical use of MCS in high-risk PCI in patients without severely depressed LVEF, defined as LVEF > 35%. Patients without cardiogenic shock from the catheter-based ventricular assist device registry, who underwent elective or urgent PCI with an Impella 2.5 or Impella CP, were included. Patients who received MCS after the start of the PCI were excluded. A total of 891 patients were included, of whom 661 had LVEF ≤ 35% and 230 had LVEF > 35%. Patients with LVEF > 35% compared with patients with LVEF ≤ 35% were older (72.12 ± 11.70 years vs 68.68 ± 11.01 years; p <0.001), had more extensive coronary artery disease with more diseased vessels (1.90 ± 0.71 vs 1.73 ± 0.79; p = 0.005), more multivessel intervention (1.74 ± 0.69 vs 1.55 ± 0.73; p <0.001), and more use of rotational atherectomy (21.21% vs 14.90%; p = 0.046), respectively. Additionally, they had a high prevalence of high-risk clinical features such as renal failure (24.89%) and diabetes mellitus (45.37%). Despite these high-risk features, the major adverse cardiovascular and cerebral event rates were favorable overall, with no differences between the 2 groups (3.48% vs 4.54%; p = 0.574). Despite having LVEF > 35%, this selected group of patients had severe co-morbidities and complex angiographic features; hence, PCI with hemodynamic support was deemed necessary. In addition, PCI with elective MCS was feasible and safe in this patient population., (Copyright © 2018 Elsevier Inc. All rights reserved.)