A woman in her mid-20s presented with cardiogenic shock. On presentation, she was afebrile with cool extremities; her blood pressure was 75/51 mm Hg, heart rate was 147 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 99% on mechanical ventilation. Her chest examination revealed bilateral coarse breath sounds and distant heart sounds. Transthoracic echocardiogram revealed an ejection fraction of 10% with elevated filling pressures and no significant valvular abnormalities. Owing to hemodynamic instability, the patient was given venoarterial extracorporeal membrane oxygenation (ECMO) with the peripheral ventricular assist device (pVAD) Impella CP (Abiomed) and was administered high-dose intravenous corticosteroids. Endomyocardial biopsy showed lymphocytic viral myocarditis. There was significant hemodynamic improvement within 48 hours; transthoracic echocardiogram was obtained and showed impressive recovery of the left ventricular function to an ejection fraction of 45%. As a result, ECMO was decannulated after 72 hours. Left pVAD support was maintained alone for another 24 hours. In the interim, her vitals remained unchanged, but the patient developed hematuria and laboratory parameters suggestive of hemolysis. Chest radiography showed pulmonary edema, and low-flow alarms sounded on the device console. Transthoracic echocardiogram showed severe mitral regurgitation (MR), and a transesophageal echocardiogram was performed to evaluate pVAD positioning (Figure and Video).
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Published Online: February 23, 2022. doi:10.1001/jamacardio.2021.6010
Correction: This article was corrected on April 13, 2022, to correct the figure legend.
Corresponding Author: Asad J. Torabi, MD, Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, 1800 N Capital Ave, Indianapolis, IN 46202 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Jeffrey E. Everett, MD, Indiana University School of Medicine, Indianapolis, for his assistance in reviewing and editing the manuscript; he did not receive financial compensation for this contribution.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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