Mixed shock after alcohol septal ablation for hypertrophic obstructive cardiomyopathy: Impella in crisis management

Abstract

Alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) can lead to complex hemodynamic challenges. This report describes a case of a 79-year-old woman who developed mixed cardiogenic and distributive shock following ASA. Cardiogenic shock occurred due to complete atrioventricular block with insufficient cardiac output despite temporary right ventricular pacing. Concurrently, distributive shock developed secondary to bacterial pneumonia and exacerbation of polymyositis-associated interstitial lung disease. Fluid resuscitation, antibiotics, vasopressors, and hydrocortisone were ineffective. Inotropes, intra-aortic balloon pump, and veno-arterial extracorporeal membrane oxygenation were contraindicated because of the risk of worsening left ventricular outflow tract obstruction. An Impella 2.5 (Abiomed Inc., Danvers, MA, USA) was deployed, achieving hemodynamic stabilization without worsening left ventricular outflow tract obstruction. The patient recovered successfully through comprehensive intensive care and was discharged. This case highlights the potential efficacy of Impella support in managing complex mixed shock states after ASA. It emphasizes the multiple challenges in HOCM management, including addressing hemodynamic complexities due to left ventricular outflow tract obstruction, managing ASA-related complications, and simultaneously treating concurrent distributive shock. This comprehensive approach is crucial for developing effective individualized management strategies for patients with HOCM when dealing with postprocedural complications.

Learning objective

This case illustrates complex hemodynamic complications following alcohol septal ablation for hypertrophic obstructive cardiomyopathy. It emphasizes the importance of recognizing and managing mixed cardiogenic and distributive shock when standard treatments fail. The case highlights the potential role of Impella (Abiomed Inc., Danvers, MA, USA) support in stabilizing hemodynamics without exacerbating left ventricular outflow tract obstruction.