CONGRESS ABSTRACT

A 66-year-old man was transferred to our Cardiology ICU for acute dyspnoea associated with posterior thoracic pain. Medical history: bioprosthetic aortic valve replacement for a bicuspid aortic valve (2002). TTE at the time of admission: left ventricular hypertrophy, mild biventricular dysfunction, severe aortic regurgitation due to leaflet prolapse in the LVOT, functional mitral regurgitation and signs of pulmonary congestion. An TEE was performed immediately and revealed bioprosthetic dysfunction due to leaflet rupture or endocarditis, but no vegetation was detected. The patient underwent urgent cardiac surgery (REDO) with bioprosthetic replacement of the aortic and mitral valves. Despite circulatory support with IABP, the patient remained hemodynamically unstable at the end of the procedure. An ETE disclosed severe left ventricular dysfunction, normal right ventricular function and apparent proper functioning of the newly implanted valves. These findings led to a diagnosis of post-operative low cardiac output syndrome (LCOS). Medical circulation support therapy was rapidly administered without clinical benefits, so three hours after surgery, an IMPELLA-CP was implanted. Invasive coronary angiography excluded coronary stenosis. However, this MCS caused right ventricular dysfunction, which led to upgrading to ECMELLA V-A. Despite our efforts, it was too late: multi-organ dysfunction had already progressed too far. Electrical instability appeared in the following hours, rapidly leading to the patient's death. DISCUSSION: Post-cardiotomy cardiogenic shock remains a serious and fatal complication of cardiac surgery that often requires pharmacological or MCS support. We present a case of successful off-label IMPELLA-CP implantation in LCOS following a new bioprosthetic aortic valve replacement; however, the failure of the procedure was attributed to the excessively advanced stage of cardiovascular impairment, which necessitated an upgrade to ECMO V-A without benefit.