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.