During the second annual Houston Shock Symposium, Sudeep Kuchibhotla, MD, a cardiology fellow at the Texas Heart Institute, presented a compelling case study of a patient with takotsubo cardiomyopathy.
The patient, a 72-year-old female presenting with fever and abdominal pain, had no prior cardiac problems but a history of diffuse large B-cell lymphoma. She began a course of antibiotics upon discovery that her fistula between segments of her small bowel was infected. On her fifth day in the hospital, she developed acute pulmonary edema, hypotension, shock liver, acute renal failure, and atrial fibrillation. She required mechanical ventilation, inotropes, and vasopressors.
On inotropes alone, her hemodynamics prior to intervention are listed in TABLE 1.
TABLE 1.
| Hemodynamic parameter | On inotropes alone |
| Right atrium (mmHg) | 21 |
| Right ventricular end diastolic pressure (mmHg) | 20 |
| Pulmonary artery (mmHg) | 29/18/24 |
| Pulmonary wedge (mmHg) | 16 |
| Cardiac index by Fick (L/min/m2) | 1.76 |
| Left ventricular end diastolic pressure (mmHg) | 21 |
| Oxygenation saturation from mixed venous blood (SvO2) | 28% |
| Pulmonary artery pulsatility index (PAPI) | 0.52 |
The patient was diagnosed with takotsubo cardiomyopathy. Based on her hemodynamic data, she received an Impella CP. After Impella was insertion, the patient’s hemodynamics were measured again while she was still in the lab. The resulting measurements are listed in Table 2.
TABLE 2.
| Hemodynamic parameter | On inotropes alone | After Impella CP |
| Right atrium (mmHg) | 21 | 22 |
| Right ventricular end diastolic pressure (mmHg) | 20 | 17 |
| Pulmonary artery (mmHg) | 29/18/24 | 29/23/25 |
| Pulmonary wedge (mmHg) | 16 | 20 |
| Cardiac index by Fick (L/min/m2) | 1.76 | 1.93 |
| Left ventricular end diastolic pressure (mmHg) | 21 | – |
| SvO2 | 28% | 33% |
| PAPI | 0.52 | 0.27 |
Because her right atrial pressure was elevated and her PAPI score of 0.27 suggested severe right ventricle failure, the patient received a TandemHeart pump 30 minutes later. After receiving the TandemHeart, the patient’s right atrium went down to 8 mmHg, and her SvO2 increased to 79 percent. On day four, the TandemHeart was explanted, and the Impella was removed on day eight. Her renal function returned to normal.
According to Dr. Kuchibhotla, one of the most important take-home messages from this case is to pay attention to the right ventricle. PAPI, right atrial pressure, and RV afterload indices should be taken into consideration when making initial cardiogenic shock management decisions.
Dr. Kuchibhotla, also said that just taking a few extra moments when evaluating patients—rather than promptly sending them out of the catherization laboratory—could impact the course of events later.
“If you do suspect [right ventricular] dysfunction based on the information you have and you place a left-sided device, it may be worth it to keep the patient in the [catherization laboratory] for an additional few minutes to see how the RV responds,” he suggested. In the case of this patient, keeping her in the lab for extra testing made a significant difference.
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