Making matters worse with Impella

Abstract

A 53-year-old man was treated with extracorporeal cardiopulmonary resuscitation with the controlled automated reperfusion of the whole body (CARL) system (Resuscitec, Germany) after a refractory in-hospital cardiac arrest following an arrhythmic storm in the setting of an episode of inflammatory cardiomyopathy. The patient required Impella-CP device implantation (Abiomed, United States) via femoral access due to insufficient unloading with the intra-aortic balloon pump. Catheter malapposition was suspected after several suction alarms were triggered. Despite repeated attempts at repositioning, flow rates remained < 1 L/min. Transesophageal echocardiography and thoracic x-ray (figure 1) confirmed that the catheter had bent in upon itself (asterisk in the figure), and the pigtail had been caught in the outlet (figure 2) following the multiple attempts at repositioning. The catheter migrated toward the descending aorta and urgent removed was decided. An attempt to unscrew the pigtail through femoral manipulation proved unsuccessful (figure 3A and video 1 of the supplementary data). A 7-Fr Amplatz Super-Stiff guidewire (Boston Scientific, United States) was advanced through the Impella loop via left radial access, and traction on the catheter from the femoral access successfully disengaged the pigtail from the outlet (figure 3B). Concurrently, a 12 mm × 20 mm EN-Snare loop (Merit Medical,...