Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Trastuzumab/pertuzumab-related refractory cardiogenic shock in locally advanced HER2-positive breast cancer (n=1). Intervention: ECMELLA support (peripheral femoro-femoral VA-ECMO combined with percutaneous Impella CP) during curative breast cancer surgery. Primary outcome: Myocardial recovery (LVEF) and hemodynamic stabilization following curative breast cancer surgery on ECMELLA support.

Q: What does this research mean for the field?

ECMELLA support can provide hemodynamic stabilization and bridge patients with HER2-blocker-induced cardiogenic shock to myocardial recovery while safely permitting curative oncologic surgery. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Alessia d’Aiello; Daniela Pedicino; Gianluca Franceschini; Sabatino D’Archi; Enrico Di Guglielmo; Ida Paris; Massimo Massetti; Andrea Scapigliati; Maria Enrica Antoniucci; Francesco Burzotta; Trani Carlo; Cristina Aurigemma; Mattia Lunardi; Giampaolo Luzi; Emilio D’Avino; Fabio Sbaraglia; Tommaso Sanna

doi:10.1186/s40959-026-00595-8

October 28, 2026Cardio-OncologyOpen Access

Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

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Key result

ECMELLA support enables curative mastectomy and recovery from refractory cardiogenic shock to ~45% LVEF.

n=1

Why the study?

Can ECMELLA mechanical circulatory support stabilize refractory cardiogenic shock from presumed trastuzumab/pertuzumab-related cardiotoxicity to enable safe curative breast cancer surgery and bridge to myocardial recovery?

Key Points

To describe the multidisciplinary management and feasibility of curative-intent breast cancer surgery in a patient experiencing refractory cardiogenic shock secondary to dual HER2 blockade.
Clinical evaluation and management of a 50-year-old woman presenting with severe left ventricular failure (LVEF approximately 10%-15%) after receiving neoadjuvant epirubicin, cyclophosphamide, paclitaxel, trastuzumab, and pertuzumab for HER2-positive breast cancer.
Hemodynamic stabilization attempted with inotropes, vasopressors, and percutaneous left ventricular assist device (Impella CP) implantation, followed by escalation to veno-arterial extracorporeal membrane oxygenation combined with Impella (ECMELLA configuration).
Multidisciplinary surgical resection of the breast tumour during full ECMELLA support under unfractionated heparin anticoagulation.
Definitive surgical removal of the breast tumour was successfully executed while maintained on full ECMELLA support.
Progressive myocardial recovery permitted successful, complete weaning from mechanical circulatory support.
The patient achieved sustained hemodynamic stability, with recovery of left ventricular ejection fraction to approximately 45% under guideline-directed heart failure therapy.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Can ECMELLA mechanical circulatory support stabilize refractory cardiogenic shock from presumed trastuzumab/pertuzumab-related cardiotoxicity to enable safe curative breast cancer surgery and bridge to myocardial recovery?

P

Population

1 50-year-old woman with locally advanced HER2-positive breast cancer who developed severe LV failure (LVEF 10-15%) and refractory cardiogenic shock after neoadjuvant dual HER2 blockade, followed for 3 months.

I

Intervention

Mechanical circulatory support escalation to ECMELLA (percutaneous femoral Impella CP combined with peripheral femoro-femoral veno-arterial extracorporeal membrane oxygenation [VA-ECMO] with unfractionated heparin targeting ACT 180-200 s), followed by curative-intent simple mastectomy with sentinel lymph node biopsy and level I-II axillary dissection performed during full ECMELLA support (VA-ECMO flow ~3.5 L/min, Impella CP at P6 with flow ~3.0 L/min), and subsequent guideline-directed medical therapy for heart failure (beta-blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and SGLT2 inhibitor).

O

Outcome

Hemodynamic stabilization, surgical completion without major complications, weaning from mechanical circulatory support, and left ventricular myocardial recovery up to 3-month follow-up.hard clinical

This case demonstrates the potential reversibility of fulminant HER2-targeted therapy-associated cardiogenic shock and shows for the first time that curative-intent breast cancer surgery can be safely performed during full ECMELLA mechanical circulatory support under multidisciplinary care.

Limitations

Single-patient case report
Coronary angiography, cardiac magnetic resonance imaging, and endomyocardial biopsy were not performed during the acute phase due to profound hemodynamic instability, so alternative diagnoses like fulminant myocarditis or Takotsubo syndrome could not be definitively excluded at presentation
Invasive hemodynamic monitoring with a pulmonary artery catheter was not performed during the initial unstable phase
Baseline high-sensitivity troponin and natriuretic peptide values were not available
Baseline high-sensitivity troponin and natriuretic peptide values before neoadjuvant therapy were not available
Coronary angiography, cardiac magnetic resonance imaging, and endomyocardial biopsy were not performed during the acute phase due to profound hemodynamic instability, so alternative diagnoses (fulminant myocarditis, Takotsubo syndrome) could not be definitively excluded at presentation
Invasive hemodynamic monitoring with a pulmonary artery catheter was not performed during the initial unstable phase, leaving cardiac index, filling pressures, pulmonary artery pressures, and mixed venous oxygen saturation unavailable

Implication

ECMELLA may permit curative surgery in select HER2 cardiotoxicity shock cases; leaves open generalizability and need for prospective validation.

Abstract

Background Trastuzumab and pertuzumab are key agents in the treatment of HER2-positive breast cancer but may cause left ventricular (LV) dysfunction. Fulminant cardiotoxicity leading to cardiogenic shock is extremely uncommon, and management strategies remain poorly defined. Case presentation We describe a patient with HER2-positive breast cancer who developed severe LV failure and refractory cardiogenic shock shortly after dual HER2 blockade. Hemodynamic stabilization was initially attempted with inotropes and vasopressors, followed by percutaneous left ventricular assist device (Impella CP) implantation. Owing to persistent circulatory collapse, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated and combined with Impella support (ECMELLA configuration). During ECMELLA, the patient underwent surgical removal of the breast tumour after multidisciplinary evaluation. Progressive myocardial recovery allowed complete weaning from mechanical circulatory support (MCS). She achieved sustained hemodynamic stability, with an LV ejection fraction (LVEF) of approximately 45% under standard heart failure therapy. Conclusions This case underscores the potential reversibility of a presumed HER2-blocker-induced fulminant cardiomyopathy and highlights the role of timely MCS escalation and coordinated cardio-oncology care, even allowing successful oncologic surgery during ECMELLA support.

Discussion

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Cite This Study

d’Aiello et al. (2026) conducted a case report in Trastuzumab/pertuzumab-related refractory cardiogenic shock in locally advanced HER2-positive breast cancer (n=1). ECMELLA support (peripheral femoro-femoral VA-ECMO combined with percutaneous Impella CP) during curative breast cancer surgery was evaluated on Myocardial recovery (LVEF) and hemodynamic stabilization following curative breast cancer surgery on ECMELLA support. ECMELLA support enabled curative mastectomy without major bleeding and bridged the patient from refractory cardiogenic shock (LVEF 10-15%) to weaning and myocardial recovery (LVEF 45% at 3 months).

synapsesocial.com/papers/6ae207b8779bd8f3826bb2bd https://doi.org/10.1186/s40959-026-00595-8

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Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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