Takotsubo cardiomyopathy with LVOT obstruction in a case of STEMI: a rare cause of peri-PCI hypotension

Takotsubo cardiomyopathy (TCM) associated with left ventricular outflow tract (LVOT) obstruction in the event of an ST-elevation myocardial infarction (STEMI) is a rare cause of hypotension during percutaneous coronary intervention (PCI). Herein, we describe a 57-year-old woman who presented with STEMI and underwent PCI. She developed hypotension which worsened during inotropic therapy. Echocardiography revealed evidence of LVOT obstruction in the setting of TCM. Therefore, inotropic support was promptly discontinued. Beta blockers and phenylephrine were rapidly administrated, resulting in improved blood pressure and stabilisation of the patient.

Abstract 15947: Predictors and Characteristics of Malignant Arrhythmias in Patients on Ambulatory Inotropic Therapy

Introduction: Ambulatory inotropic therapy (AIT) is used in advanced heart failure as a bridge to advanced therapies or palliation. Inotropes are known arrhythmogenic agents. The characteristics, predictors and outcomes of ventricular tachycardia (VT) and ventricular fibrillation (VF) in this population are not well studied. Methods: This is a retrospective analysis of patients discharged on AIT. Patients were followed from AIT initiation until transplant, ventricular assist device placement, death, or wean from inotropes. Those without an ICD were excluded. All data was obtained through chart review. Results: We included 160 patients (mean age 60±13 years; 70% male). Milrinone was the selected inotrope in 94%. VT/VF occurred in 37/160 (23%) a median 2.6 months after AIT initiation. 20/37 (54%) had a VT/VF event within 3 months. 25/160 (16%) received ICD shocks and 40/160 (25%) received anti-tachycardia pacing (ATP). Inappropriate shocks for atrial arrhythmias occurred in 5 (3.1%). Of 59 episodes with available interrogation data, 70% were VT and 30% were VF. ATP successfully resolved 18/59 (14%), shocks were used in 33/59 (56%), and 8/59 (14%) resolved without device therapy. The mean VT cycle length was 284±63 ms with an average VT/VF time of 44±99 seconds. In univariate analysis previous VT/VF was predictive of VT/VF on AIT (HR: 2.54; 95% CI 1.33-5.86; p=0.01). Beta blocker therapy was protective (HR: 0.45; 95% CI 0.21-0.99; p=.05). Those patients with a VT/VF event in the first 3 months of AIT have higher 1 year mortality (80.4% vs 87.7%, p=0.02, Fig. 1). Prior to AIT initiation, VT/VF had occurred in 52 (33%) patients. Of the 108 patients with no history of VT/VF prior to AIT initiation, 19 (18%) had a de novo episode of VT/VF. Conclusions: Patients on AIT are at risk of ventricular arrhythmias. Those with previous VT/VF are at increased risk, but 15-20% with no previous events will have VT/VF. VT/VF within 3 months of AIT initiation may worsen prognosis and increase mortality.

“I Just Feel Like I Always Did”: Inotropic Dependency at End of Life

Background: Patients not considered for mechanical circulatory support or heart transplant may be dependent on inotropic therapy at end of life. End-of-life conversations in advanced heart failure can be challenging for providers, but guidelines recommend frequent goals-of-care conversations when inotropes are used as a palliative treatment. The purpose of this study was to identify aspects of care pertinent for health-care professionals working with patients in end-stage heart failure who are receiving continuous inotropic support. Methods: Qualitative analysis was used to examine 3 audio-recorded semistructured interviews with 1 patient, her family, and her cardiologist. The selected patient was an older adult, diagnosed with advanced heart failure, and dependent on continuous inotropic therapy with no other advanced treatment options available. Results: The analysis revealed that (1) reliance on others, (2) contending with uncertainty, and (3) deciding when to discontinue inotropic support were identified as themes central to the patient’s and provider’s experience. Conclusion: This study offers insight into how to best support and communicate with patients having advanced heart failure who are dependent on continuous inotropic therapy at end of life.

Epinephrine, inodilator, or no inotrope in venoarterial extracorporeal membrane oxygenation implantation: a single-center experience

Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be a rescue therapy for patients in cardiogenic shock or in refractory cardiac arrest. After cannulation, vasoplegia and cardiac depression are frequent. In literature, there are conflicting data on inotropic therapy in these patients. Methods Analysis of a retrospective registry of all patients treated with VA-ECMO in a university hospital center between October 2010 and December 2018 for cardiogenic shock or extracorporeal cardiopulmonary resuscitation (eCPR) with a focus on individual early inotropic therapy. Results A total of 231 patients (age 58.6 ± 14.3, 29.9% female, 58% eCPR, in-house survival 43.7%) were analyzed. Of these, 41.6% received no inotrope therapy within the first 24 h (survival 47.9%), 29.0% received an inodilator (survival 52.2%), and 29.0% received epinephrine (survival 25.0%). Survival of patients with epinephrine was significantly worse compared to other patient groups when evaluating 30-day survival (p = 0.034/p = 0.005) and cumulative incidence of in-hospital death (p = 0.001). In a multivariate logistic regression analysis, treatment with epinephrine was associated with mortality in the whole cohort (OR 0.38, p = 0.011) as well as after propensity score matching (OR 0.24, p = 0.037). We found no significant differences between patients with inodilator treatment and those without. Conclusion Early epinephrine therapy within the first 24 h after cannulation for VA-ECMO was associated with poor survival compared to patients with or without any inodilator therapy. Until randomized data are available, epinephrine should be avoided in patients on VA-ECMO.