Kawakami Shoji, Nawata Eigo, Nishi Jun-Ichiro
Department of Cardiology, Aso Iizuka Hospital, 3-83 Yoshio-machi, Iizuka, Fukuoka 820-8505, Japan.
Eur Heart J Case Rep. 2024 Oct 24;8(11):ytae578. doi: 10.1093/ehjcr/ytae578. eCollection 2024 Nov.
It is reasonable to introduce a microaxial flow pump (Impella) before coronary angiography and left ventriculography (LVG) to prioritize treating tissue hypoperfusion in patients with takotsubo syndrome (TTS) and refractory cardiogenic shock. However, left ventricular (LV) unloading by an Impella device might prevent contrast media from filling the left ventricle, making it difficult to evaluate LV wall motion abnormalities during LVG.
A 76-year-old female with ST elevations in I, II, aVL, and V1-6 on electrocardiography and severe LV dysfunction on echocardiography immediately received circulatory support with Impella CP to treat refractory cardiogenic shock. Subsequent coronary angiography showed no significant stenosis. Biplane LVG was performed using an additional pigtail catheter inserted into the left ventricle while the pump catheter remained there in temporary surgical mode, which was able to protect the motor because the purge system remained active while the pump was stopped. Left ventriculography in temporary surgical mode revealed apical ballooning with a mismatch between epicardial coronary artery perfusion and LV contraction without compromised haemodynamics. The patient was diagnosed with TTS.
Coronary angiography and LVG are considered essential diagnostic tools to confirm TTS and exclude acute myocardial infarction. Left ventriculography with Impella temporarily set to surgical mode was able to clearly evaluate LV wall motion abnormalities without affecting haemodynamics. This case highlights that it is perfectly acceptable to prioritize Impella insertion over coronary angiography and LVG in patients with refractory cardiogenic shock in whom the differentiation between TTS and acute myocardial infarction has not yet been made.
在冠状动脉造影和左心室造影（LVG）之前引入微轴流泵（Impella）以优先治疗应激性心肌病（TTS）和难治性心源性休克患者的组织灌注不足是合理的。然而，Impella装置对左心室（LV）的卸载可能会阻止造影剂充盈左心室，从而难以在LVG期间评估左心室壁运动异常。
一名76岁女性，心电图显示I、II、aVL及V1 - 6导联ST段抬高，超声心动图显示严重左心室功能障碍，立即接受Impella CP循环支持以治疗难治性心源性休克。随后的冠状动脉造影显示无明显狭窄。在泵导管以临时手术模式留在原处的情况下，通过额外插入左心室的猪尾导管进行双平面LVG，由于在泵停止时冲洗系统仍处于活动状态，因此能够保护电机。临时手术模式下的左心室造影显示心尖气球样变，心外膜冠状动脉灌注与左心室收缩不匹配，且血流动力学未受影响。该患者被诊断为TTS。
冠状动脉造影和LVG被认为是确诊TTS和排除急性心肌梗死的重要诊断工具。将Impella临时设置为手术模式进行左心室造影能够在不影响血流动力学的情况下清晰评估左心室壁运动异常。该病例强调，在尚未明确区分TTS和急性心肌梗死的难治性心源性休克患者中，优先插入Impella而非进行冠状动脉造影和LVG是完全可以接受的。
