Rethinking Right Ventricular Shock: Right Ventricular Assist Device as a Bailout Strategy in Cardiogenic Shock After Right Ventricle Infarction

Introduction/Background:

Cardiogenic shock due to right ventricular (RV) dysfunction poses significant risks, with few treatment options when fluid optimization and inotropes fail. The Impella right-sided heart pump (Impella RP) offers rapid hemodynamic restoration, which is crucial for patients in cardiogenic shock.

Description:

A 68-year-old female presented with syncope, hypotension, and cardiac arrest. Coronary angiography revealed a small right coronary with an ostial occlusion, too small for intervention. She remained unstable despite fluids and inotropes. After cardiac arrest, echocardiography demonstrated RV dilation and hypokinesis with preserved apical function which suggested acute RV dysfunction. Right heart catheterization demonstrated a severely reduced cardiac index of 0.9 L/min/m2 and pulmonary artery pulsatility index of 0.7, which led to the timely consideration of mechanical support. Due to single ventricle shock, the heart team felt she was an ideal candidate for Impella RP. An Impella RP was placed, resulting in immediate hemodynamic improvement. Support was able to be weaned and successfully removed without major complications. RV function normalized on echocardiogram prior to discharge.

Discussion:

Treating isolated RV shock is complex. Abnormal RV strain with preserved apical function suggested RV reserve. Impella RP is a promising percutaneous therapy offering early RV unloading, potentially hastening recovery from RV shock, particularly when reperfusion is not feasible.