Management/Interventions:
A right heart catheterization was performed (figure I, table II). The
initial pulmonary artery pulsatility index (PAPi) was 0.535 and his
cardiac power output was 0.47 consistent with severe biventricular
failure. An impella CP was placed via the right femoral artery. He was
monitored in the cath lab for 30 minutes and repeat right heart
catheterization was performed (figure II):
Repeat PAPi was 0.73 demonstrating minimal improvement in RV function
with LV offloading. The RA:PCWP was 1.04 which was unchanged from the
initial measurement prior to impella CP placement and the RV stroke work
index (RVSWI) improved modestly from 3.2 to 4.5, but was still
significantly reduced, indicative of severe RV dysfunction. At that
point an RP impella was placed and repeat hemodynamics showed improved
biventricular function (figure III, table II) with an improved PAPi of
1.04 and an RA: PCWP of 0.88. He was then transferred to the CCU for
further management.
In the CCU, he was placed on PTU, hydrocortisone, cholestyramine,
lugol’s solution, and propranolol for management of his hyperthyroidism
and rate control.
Over the course of 3 days his lactate, renal and hepatic function
normalized. He developed mild hemolysis, hematuria, and
thrombocytopenia, all of which resolved shortly after device weaning
(table I).
On hospital day 3 echocardiograhy showed modest improvement in the right
ventricular function prompting removal of the RP impella. He was
aggressively diuresed and on hospital day 4 the impella CP was weaned
off and removed.
Diuresis and uptitration of guideline directed medical therapy for heart
failure were continued over several days. On hospital day 8 he underwent
successful TEE/DCCV. Prior to discharge repeat echocardiogram showed
marked improvement with an ejection fraction of 35% and normal right
ventricular function by TAPSE. On discharge he was taking metoprolol
succinate, lisinopril, furosemide, apixaban, and methimazole.
Clinical Follow up: Three months later he was asymptomatic and had an
echocardiogram that showed normalized cardiac function.