Short-term Mechanical Circulatory Support by “ECMELLA” concept including Impella5® as Bridge-to-full-Recovery in patient suffering cardiac arrest due to fulminant Arrhythmia-induced Cardiomyopathy

Mintje Bohné (Hamburg)1, E. Bahlmann (Hamburg)1, R. Gramlich (Hamburg)1, J. Hartmann (Hamburg)2, S. Willems (Hamburg)1, E. P. Tigges (Hamburg)1

1Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; 2Asklepios Klinik St. Georg Interventionelle Kardiologie und Elektrophysiologie Hamburg, Deutschland


Background: Tachycardia such as atrial fibrillation and atrial flutter are known to trigger a reversible dilated cardiomyopathy referred as Arrhythmia-induced Cardiomyopathy (AiCM). AiCM should be suspected in patients with a mean heart rate above 100 bpm showing symptoms of heart failure. Reversal of cardiomyopathy (CM) by elimination of the arrhythmia confirms AiCM. 
Clinical presentation is various, includes cardiogenic shock, and can be fatal. Diagnosis is based on clinical examination, electrocardiogram and echocardiography. Mechanical Circulatory Support (MCS) can be required in patients with severe cardiogenic shock or even cardiac arrest. Among the available MCS options the “ECMELLA” concept is a combination of left ventricular (LV) venting by Impella® devices (Abiomed) and extracorporeal life support (ECLS). 
Impella5® is an intravascular microaxial blood pump that provides maximum average blood flow up to 5 l/min. MCS therapy can provide the necessary hemodynamic support in the treatment of cardiogenic shock, including diagnostic and specific therapies like catheter ablation in patients in need of hemodynamic support, while allowing restitution of myocardial function in reversible CM such as AiCM. 
Case Presentation: We report a case of a 60‐year‐old male who presented with a history of shortness of breath and documented supraventricular tachycardia. Electrocardiogram confirmed atrial flutter (AF) with a heart rate of 150 bpm. Clinical examination showed signs of acute heart failure, therefore the patient was admitted to intensive care unit and antiarrhythmic medical therapy with amiodarone was initiated. Due to further hemodynamic deterioration, ongoing AF and severely reduced LV function, electrical cardioversion was performed. The patient subsequently suffered from cardiac arrest. Cardiopulmonary resuscitation was immediately initiated and due to pulseless electrical activity patient’s stabilization required MCS via ECLS by means of veno‐arterial extracorporeal membrane oxygenation (VA-ECMO). Atrial fibrillation persisted despite therapy, LV-function was still severely impaired. 
MCS was escalated to the “ECMELLA” concept by adding Impella5® to provide LV venting. VA-ECMO was weaned and removed two days after Impella5® lmplantation. 
To allow restitution of myocardial function the patient underwent catheter ablation under MCS via Impella5®. Pulmonary vein isolation for atrial fibrillation and radiofrequency cavotricuspid isthmus ablation for atrial flutter were successfully performed and sinus rhythm could be resorted. Imeplla5® was removed after 15 days.  
The patient was transferred to a rehabilitation clinic 5 weeks after admission with fully restored cardiac function and in good neurological state. 
In fulminant AiCM hemodynamic support to treat cardiogenic shock and provide the required period for specific therapy like catheter ablation can be achieved by MCS via the “ECMELLA” concept including Impella5®. The gained period allows restitution of myocardial function in reversible CM as a bridge-to-full-recovery. 
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