Background: Intramural dissecting hematoma (IDH) is a rare complication of myocardial infarction, associated with poor prognosis and high mortality, particularly in cardiogenic shock. While conservative management may be feasible in selected stable patients, surgical repair is often the only treatment option. We present a case demonstrating successful use of mechanical circulatory support (MCS) as a bridge to recovery in cardiogenic shock due to IDH, highlighting a potential alternative strategy in this high-risk setting.
Case presentation: A 41-year-old man was referred to our centre for advanced MCS due to prolonged deteriorating infarct-related cardiogenic shock and a left ventricular IDH. Three days earlier, he had been diagnosed with subacute anterior myocardial infarction. Coronary angiography revealed total occlusion of the left anterior descending artery (LAD). Recanalization attempt was not successful. Cardiac computed tomography (CT), transthoracic-, and transesophageal echocardiography upon admission to our centre revealed an IDH in the LAD territory. Left ventricular ejection fraction (LVEF) was severely reduced (approx. 5%). Owing to hemodynamic instability, a microaxial intravascular flow pump (Impella CP, Abiomed) was implanted, followed by escalation to a veno-arterial extracorporeal membrane oxygenation (VA-ECMO; Novalung, Fresenius Medical Care). Upon the mechanical support, Levosimendan therapy was initiated, and continuous venovenous hemodiafiltration was started due to acute kidney injury.
Notably, the VA-ECMO drainage cannula tip was located in the left atrium via a patent foramen ovale, resulting in a left atrial–veno-arterial (LAV-A) ECMO configuration. The achieved hemodynamic stability allowed an exchange of the VA-ECMO system following hospital standard care and expertise (Cardiohelp, Getinge).
Ten days after admission, we escalated the intravascular flow pump support to an Impella 5.5 system (Abiomed) for weaning the VA-ECMO support, which was successfully completed the following day. Prolonged ventilation required a percutaneous tracheostomy during the second week. Subsequently the patient was gradually weaned from the ventilatory support, MCS, and renal replacement therapy, which were both discontinued by week four.
After seven weeks, a follow-up cardiac Magnetic resonance imaging (MRI) confirmed apersistent IDH and an improved LVEF (ca. 20%). Guideline-directed heart failure therapy was initiated and well tolerated. No neurological impairment was present, and cerebral CT showed no abnormalities. After multidisciplinary Heart Team discussion, a conservative strategy was established, and the patient was discharged on day 49 to a cardiac rehabilitation centre. For primary prevention of sudden cardiac death, the patient was fitted with a wearable defibrillator.
The patient was enrolled in our heart failure and telemedicine follow-up programs. Three months after admission he remained clinically stable. A next follow-up evaluation was scheduled.
Conclusion: This case demonstrates successful recovery in a patient presenting with infarct-related IDH and coexisting cardiogenic shock through temporary MCS including the use of an Impella 5.5 system (Abiomed) and VA ECMO. It underscores the value of a multidisciplinary, stepwise approach and the importance of continued ambulatory and telemedical care in achieving favourable outcomes in otherwise fatal clinical scenarios.
