Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report

Abstract

Background The value of mechanical circulatory support (MCS) in cardiogenic shock, especially the combination of the ECMELLA approach (Impella combined with ECMO), remains controversial. Case presentation A previously healthy 33-year-old female patient was submitted to a local emergency department with a flu-like infection and febrile temperatures up to 39 °C. The patient was tested positive for type-A influenza, however negative for SARS-CoV-2. Despite escalated invasive ventilation, refractory hypercapnia (paCO2: 22 kPa) with severe respiratory acidosis (pH: 6.9) and a rising norepinephrine rate occurred within a few hours. Due to a Horovitz-Index < 100, out-of-centre veno-venous extracorporeal membrane oxygenation (vv-ECMO)-implantation was performed. A CT-scan done because of anisocoria revealed an extended dissection of the right vertebral artery. While the initial left ventricular function was normal, echocardiography revealed severe global hypokinesia. After angiographic exclusion of coronary artery stenoses, we geared up LV unloading by additional implantation of an Impella CP and expanded the vv-ECMO to a veno-venous-arterial ECMO (vva-ECMO). Clinically relevant bleeding from the punctured femoral arteries resulted in massive transfusion and was treated by vascular surgery later on. Under continued MCS, LVEF increased to approximately 40% 2 days after the initiation of ECMELLA. After weaning, the Impella CP was explanted at day 5 and the vva-ECMO was removed on day 9, respectively. The patient was discharged in an unaffected neurological condition to rehabilitation 25 days after the initial admission. Conclusions This exceptional case exemplifies the importance of aggressive MCS in severe cardiogenic shock, which may be especially promising in younger patients with non-ischaemic cardiomyopathy and potentially reversible causes of cardiogenic shock. This case impressively demonstrates that especially young patients may achieve complete neurological restoration, even though the initial prognosis may appear unfavourable.

Influenza Myopericarditis and Pericarditis: A Literature Review

“…Our literature review identified 75 unique cases (55 adult and 20 pediatric patients) from 56 case reports, and 5 case series describing 2 to 8 patients each, published from 1959 through 2021 [ 2 , 12 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ,…”

“…Circulatory support consisted of inotropes/vasopressors (used in 58.7% of the cases) and MCS, including extracorporeal membrane oxygenation (ECMO), in 18 cases (24%), intra-aortic balloon pump (IABP) in 9 (12%), and ventricular assist device (VAD) in 7 cases (9.3%). VAD devices used were Impella in four cases [ 20 , 25 , 34 , 60 ], Bi-VAD in two, and catheter-based VAD in one case [ 18 , 50 , 68 ]. Only 1 out of 17 patients with isolated pericarditis required inotropic/vasopressor support compared to 44 out of 58 myopericarditis cases ( p < 0.001).…”

“…Fulminant myopericarditis cases with cardiogenic shock may require inotropic support along with short-term MCS (e.g., IABP, ECMO, or VAD) as a bridge to myocardial recovery [ 11 ]. Almost half of the analyzed cases were managed with a similar approach: initially with inotropic infusion, but ultimately two-thirds progressed to temporary MCS, including simultaneous ECMO with IMPELLA (ECMELLA) in three cases [ 20 , 25 , 60 ].…”