Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy
<b>Background and Clinical Significance:</b> Takotsubo cardiomyopathy (TCM), an acute stress-induced left ventricular dysfunction, stems from catecholaminergic surges leading to transient myocyte stunning, calcium overload, and microvascular dysregulation. Although most cases resolve spo...
Saved in:
| Main Authors: | , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
MDPI AG
2025-04-01
|
| Series: | Reports |
| Subjects: | |
| Online Access: | https://www.mdpi.com/2571-841X/8/2/43 |
| Tags: |
Add Tag
No Tags, Be the first to tag this record!
|
| _version_ | 1850165069403389952 |
|---|---|
| author | Ajay Saraf Amit Goyal |
| author_facet | Ajay Saraf Amit Goyal |
| author_sort | Ajay Saraf |
| collection | DOAJ |
| description | <b>Background and Clinical Significance:</b> Takotsubo cardiomyopathy (TCM), an acute stress-induced left ventricular dysfunction, stems from catecholaminergic surges leading to transient myocyte stunning, calcium overload, and microvascular dysregulation. Although most cases resolve spontaneously, roughly 10% deteriorate into fulminant cardiogenic shock, warranting mechanical circulatory support (MCS). Impella<sup>®</sup> provides direct transvalvular LV unloading but carries elevated risks of hemolysis, vascular compromise, and thrombogenicity. Conversely, the intra-aortic balloon pump (IABP) enhances diastolic coronary perfusion and marginally reduces afterload via counterpulsation, albeit with less potent LV decompression. Optimal MCS selection in TCM-associated shock therefore hinges on balancing hemodynamic benefits against procedural morbidity. <b>Case Presentation:</b> A 72-year-old female with coronary artery disease, paroxysmal atrial fibrillation (status post–left atrial appendage occlusion), and stage 3 chronic kidney disease presented with anterior ST-segment elevations (V2–V4) and troponin I >1000 ng/L, progressing rapidly to cardiogenic shock and respiratory failure. Coronary angiography revealed mild luminal irregularities, while echocardiography demonstrated severely reduced ejection fraction (5–10%) with characteristic apical ballooning. Refractory elevations in pulmonary capillary wedge pressure, despite escalating inotropes and vasopressors, prompted IABP insertion for partial LV offloading. Over one week, her ejection fraction improved to 35%, facilitating weaning from pressor support, extubation, and discharge on guideline-directed medical therapy. <b>Conclusions:</b> In TCM complicated by shock, meticulous MCS selection is paramount. Although Impella confers more robust unloading, heightened device-related complications may be unjustified in a largely reversible disease. IABP can sufficiently stabilize hemodynamics, enable myocardial recovery, and mitigate morbidity, underscoring the importance of individualized decision-making in TCM-related shock. Importantly, no trial has shown that MCS confers a proven long-term mortality benefit beyond initial hemodynamic rescue. |
| format | Article |
| id | doaj-art-ae303b8097214219a69017a6bb22d1c0 |
| institution | OA Journals |
| issn | 2571-841X |
| language | English |
| publishDate | 2025-04-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Reports |
| spelling | doaj-art-ae303b8097214219a69017a6bb22d1c02025-08-20T02:21:50ZengMDPI AGReports2571-841X2025-04-01824310.3390/reports8020043Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo CardiomyopathyAjay Saraf0Amit Goyal1Internal Medicine Residency, Boonshoft School of Medicine, Wright State University, Dayton, OH 45435, USACardiovascular Medicine, Premier Heart Institute, Boonshoft School of Medicine, Wright State University, Dayton, OH 45435, USA<b>Background and Clinical Significance:</b> Takotsubo cardiomyopathy (TCM), an acute stress-induced left ventricular dysfunction, stems from catecholaminergic surges leading to transient myocyte stunning, calcium overload, and microvascular dysregulation. Although most cases resolve spontaneously, roughly 10% deteriorate into fulminant cardiogenic shock, warranting mechanical circulatory support (MCS). Impella<sup>®</sup> provides direct transvalvular LV unloading but carries elevated risks of hemolysis, vascular compromise, and thrombogenicity. Conversely, the intra-aortic balloon pump (IABP) enhances diastolic coronary perfusion and marginally reduces afterload via counterpulsation, albeit with less potent LV decompression. Optimal MCS selection in TCM-associated shock therefore hinges on balancing hemodynamic benefits against procedural morbidity. <b>Case Presentation:</b> A 72-year-old female with coronary artery disease, paroxysmal atrial fibrillation (status post–left atrial appendage occlusion), and stage 3 chronic kidney disease presented with anterior ST-segment elevations (V2–V4) and troponin I >1000 ng/L, progressing rapidly to cardiogenic shock and respiratory failure. Coronary angiography revealed mild luminal irregularities, while echocardiography demonstrated severely reduced ejection fraction (5–10%) with characteristic apical ballooning. Refractory elevations in pulmonary capillary wedge pressure, despite escalating inotropes and vasopressors, prompted IABP insertion for partial LV offloading. Over one week, her ejection fraction improved to 35%, facilitating weaning from pressor support, extubation, and discharge on guideline-directed medical therapy. <b>Conclusions:</b> In TCM complicated by shock, meticulous MCS selection is paramount. Although Impella confers more robust unloading, heightened device-related complications may be unjustified in a largely reversible disease. IABP can sufficiently stabilize hemodynamics, enable myocardial recovery, and mitigate morbidity, underscoring the importance of individualized decision-making in TCM-related shock. Importantly, no trial has shown that MCS confers a proven long-term mortality benefit beyond initial hemodynamic rescue.https://www.mdpi.com/2571-841X/8/2/43takotsubo cardiomyopathycardiogenic shockmechanical circulatory supportintra-aortic balloon pumpImpellastress-induced cardiomyopathy |
| spellingShingle | Ajay Saraf Amit Goyal Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy Reports takotsubo cardiomyopathy cardiogenic shock mechanical circulatory support intra-aortic balloon pump Impella stress-induced cardiomyopathy |
| title | Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy |
| title_full | Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy |
| title_fullStr | Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy |
| title_full_unstemmed | Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy |
| title_short | Shock and Awe: The Tactical Trade-Offs of Impella<sup>®</sup> Versus Intra-Aortic Balloon Pump in Takotsubo Cardiomyopathy |
| title_sort | shock and awe the tactical trade offs of impella sup r sup versus intra aortic balloon pump in takotsubo cardiomyopathy |
| topic | takotsubo cardiomyopathy cardiogenic shock mechanical circulatory support intra-aortic balloon pump Impella stress-induced cardiomyopathy |
| url | https://www.mdpi.com/2571-841X/8/2/43 |
| work_keys_str_mv | AT ajaysaraf shockandawethetacticaltradeoffsofimpellasupsupversusintraaorticballoonpumpintakotsubocardiomyopathy AT amitgoyal shockandawethetacticaltradeoffsofimpellasupsupversusintraaorticballoonpumpintakotsubocardiomyopathy |