Improvement of persistent anuria in severe myocardial infarction: the potential role of Impella 5.5 as a bridge to decision

Figures

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  Figure 1. Electrocardiogram (A,B), chest radiograph (C) and coronary angiography (D,E). ECG revealed sinus rhythm with ST-segment elevation at the lateral and posterior leads (A). However, 25 min after arrival, ECG showed a complete right bundle branch block (B), followed by a deterioration of blood pressure. Chest radiography revealed mild pulmonary congestion. Emergency coronary angiography indicated total occlusion of the ostial left anterior descending (LAD) artery and proximal left circumflex artery (LCX) (D). Thrombus aspiration for LCX and drug-eluting stent implantation for LAD were supported with Impella CP (E).

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  Figure 2. Clinical course after admission. Blood pressure, urine volume, mixed venous oxygen saturation (SvO2), central venous oxygen saturation (ScvO2) and serum lactate level are shown as graphs. Grey area indicates pulse pressure. Although mean blood pressure, SvO2 and ScvO2 were within acceptable levels, anuria continued for 1 month. To control pulmonary congestion, volume reduction using continuous renal replacement therapy was necessary. However, pulse pressure and SvO2/ScvO2 gradually decreased after day 30 because of volume reduction. On day 37, serum lactate level increased under dobutamine support, necessitating mechanical circulatory support. One week after Impella 5.5 insertion, anuria resolved for the first time in a month. Two weeks after Impella 5.5 insertion, urine volume reached >2000 mL/day. The patient was transferred to another hospital for consideration of left ventricular assist device implantation or heart transplantation (HTx). BP, blood pressure; CRRT, continuous renal replacement therapy; DOB, dobutamine; NA, norepinephrine; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen saturation.

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  Figure 3. Echocardiography. Mitral regurgitation was trivial on admission (A). However, the left ventricle dilated gradually, followed by a deterioration of mitral regurgitation (B). After Impella 5.5 insertion, mitral regurgitation improved (C).