Escalation to a right-axillary Impella 5.5 restored perfusion and reversed organ dysfunction in a 76-year-old man with ADHF and AF RVR complicated by beta-blocker-induced cardiogenic shock.
Case Report (n=1)
In patients with acute decompensated heart failure and atrial fibrillation with rapid ventricular response, rate control with beta-blockers can precipitate cardiogenic shock, which may be successfully managed with early escalation to higher-flow temporary mechanical circulatory support.
Abstract Background Rate control of atrial fibrillation with rapid ventricular response (AF RVR) in acute decompensated heart failure (ADHF) is challenging, as negative chronotropes can exacerbate hemodynamic compromise and precipitate cardiogenic shock. When pharmacologic therapy worsens perfusion, temporary mechanical circulatory support (tMCS) may serve as a critical bridge to stabilization and recovery. Case Summary A 76-year-old man with chronic kidney disease and heart failure with reduced ejection fraction (LVEF 40%) presented with dyspnea, oliguria, and rising creatinine, consistent with acute decompensation. Echocardiography revealed an LVEF of 20–25% with severe global hypokinesis. In the emergency department, he was tachycardic in AF RVR (150 bpm) but normotensive. Initial therapy included intravenous metoprolol and amiodarone, and he was admitted to a medical-surgical floor.Persistent tachycardia over the next 48 hours prompted escalation of oral β-blocker therapy for rate control. This was followed by progressive deterioration with worsening dyspnea, diaphoresis, and hypoperfusion on hospital day 3 (lactate 3.5 mmol/L). He was transferred to the cardiovascular intensive care unit and became unresponsive during transport, requiring emergent intubation and epinephrine infusion. Arterial blood gas immediately after intubation demonstrated severe metabolic acidosis (pH 7.06, lactate 7.7 mmol/L), consistent with post-arrest physiology.A femoral Impella CP was implanted emergently, providing 3.1–3.3 L/min of flow and a cardiac power output (CPO) of 0.5 W. After electrical cardioversion to sinus rhythm, the patient remained in refractory shock despite dobutamine therapy. Within six hours, circulatory support was escalated to a right-axillary Impella 5.5, resulting in immediate improvement in mean arterial pressure, rapid lactate clearance, and resolution of shock. He was extubated the following day and weaned from tMCS on postoperative day 3. Lactate normalized, renal function returned to baseline, and hepatic indices improved. Discussion This case highlights the risk of β-blocker use for rate control during ADHF with hypoperfusion, the utility of the SCAI shock framework for timely escalation, and the physiologic benefit of early tMCS advancement. The axillary Impella 5.5 provides higher flow at lower RPMs, potentially reducing hemolysis while allowing patient ambulation and improved recovery. Conclusion Rate control in ADHF with AF RVR should be individualized, avoiding β-blockers when hypoperfusion is present. Early escalation to higher-flow tMCS can restore perfusion, reverse organ dysfunction, and prevent progression to irreversible shock. This abstract is funded by: None
Kobleur et al. (Fri,) conducted a case report in Acute decompensated heart failure with atrial fibrillation with rapid ventricular response (n=1). Temporary mechanical circulatory support (Impella CP escalated to Impella 5.5) was evaluated. Escalation to a right-axillary Impella 5.5 restored perfusion and reversed organ dysfunction in a 76-year-old man with ADHF and AF RVR complicated by beta-blocker-induced cardiogenic shock.
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