Impella Mechanical Circulatory Support for Takotsubo Syndrome with Shock

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Takotsubo syndrome (TS) is an acute heart failure syndrome with severely depressed left ventricular ejection fraction (LVEF) and increased left ventricular end-diastolic pressure, demonstrating the severe combined systolic and diastolic failure. Dr Napp described how TS is often misdiagnosed as acute coronary syndrome, as about 75% of patients present with angina and about 50% present with ST-segment elevation.1 Both the short- and long-term prognosis is poor, with about 10% of patients developing cardiogenic shock (CS) and death in about 4%.1,2 Catecholamine release is considered to play a causal role in TS, as it may aggravate outflow tract obstruction. Therefore, the management of TS with CS is often difficult because first-line therapies for CS are often inotropes and vasopressors, acutely worsening the severity of the disease.3,4 Of note, the systolic function in TS often recovers as long as the shock is survived, that is, patients can be bridged to recovery. Thus, temporary mechanical circulatory support devices are an attractive option for therapy.5–7 However, veno-arterial extracorporeal membrane oxygenation increases afterload with limited myocardial recovery, while intra-aortic balloon pump induces or aggravates left ventricular outflow tract obstruction in TS.

Dr Napp hypothesised that Impella support is effective as a bridge to recovery in TS-related CS. His team identified TS patients supported with Impella in Europe and the US, and analysed patient characteristics and in-hospital outcomes.

A total of 20 TS patients supported with an Impella pump (six with Impella 2.5, 13 with Impella CP and one with Impella 5.0) from 10 centres in Europe and the US were identified (age 61.5 ± 17.1 years, 80% female). Eleven patients had an apical TS type and seven patients had a physical trigger. Patients were on multiple catecholamines prior to Impella (average of 2.3 ± 0.6) and had a mean systolic blood pressure of 100.5 ± 25.4 mmHg. Most patients (88.9%) were mechanically ventilated, and 38.9% sustained cardiac arrest requiring cardiopulmonary resuscitation prior to Impella. Of the 20 patients, 16 (80%) survived to discharge, with two of the non-survivors dying from causes unrelated to shock. Patients experienced myocardial recovery with a significant improvement of LVEF at discharge compared to baseline (22.5% ± 11.0% on admission versus 55.0% ± 4.8% before discharge, p<0.001).

This is the first case series to report the use of mechanical support with the Impella ventricular assist device in patients with TS. Despite the presence of refractory CS in the majority of patients, Impella support was associated with survival of 80% and myocardial recovery in surviving patients. Additional prospective studies on Impella support in TS with shock are needed to avoid the use of catecholamines and to increase survival.


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