Abstract Introduction Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) carries 40-50% mortality despite reperfusion and pharmacologic therapy. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can stabilize refractory CS, but outcomes hinge on timing, patient selection, and bridging strategy. We present AMI-CS complicated by ventricular tachycardia (VT) storm requiring two VA-ECMO runs with Impella support, successfully bridged to durable left ventricular assist device (LVAD). Case Report A 57-year-old-male with hypertension, hyperlipidemia, and tobacco use without prior heart failure presented with anterior ST-elevation myocardial infarction (STEMI). Angiography revealed triple-vessel disease with complete left anterior descending (LAD) and circumflex occlusion. He underwent percutaneous coronary intervention (PCI) with drug-eluding stent to the LAD and intra-aortic balloon pump (IABP) placement but remained in CS despite vasopressors. Repeat PCI with circumflex thrombectomy was performed, followed VA-ECMO cannulation. Hemodynamics improved, lactate cleared, pressors were weaned, and ECMO was decannulated after stabilization. During his ICU course, he experienced multiple prolonged ventricular arrhythmic arrests, each requiring over 10 minutes of CPR before return of spontaneous circulation (ROSC). Despite antiarrhythmic therapy, he later developed refractory VT storm necessitating over 20 defibrillations, multiple ACLS interventions, re-intubation, Impella placement for LV unloading, and re-cannulation for VA-ECMO. His course was complicated by respiratory failure, MRSA/Klebsiella pneumonia, bacteremia, epistaxis requiring balloon tamponade, and acute kidney injury. Despite these, myocardial injury and hemolysis markers improved, and end-organ function recovered. He was ultimately transferred on combined VA-ECMO and Impella support, underwent LVAD implantation, and was discharged neurologically intact. Figure 1 illustrates the clinical timeline, lactate trend, and interval chest radiographs. Discussion This case demonstrated VA-ECMO under optimal conditions: early initiation in salvageable physiology, preserved neurologic status, and a defined bridge-to-device plan. VT storm, rarely cited as an ECMO indication, was successfully managed. Repeat cannulation, often associated with futility, proved effective when paired with LVAD transition. The combination of VA-ECMO and Impella (“ECpella”) optimized ventricular unloading and systemic perfusion. A concern in femoral VA-ECMO is Harlequin (North-South) syndrome, where retrograde ECMO flow mixes with desaturated left ventricular output, risking cerebral hypoxemia. Right radial arterial monitoring allows early detection. Although not observed here, vigilance was warranted. Despite multiple complications, this case underscores that when applied under best-practice conditions, VA-ECMO can serve as a life-saving bridge to durable LVAD in AMI-CS complicated by refractory arrhythmias. This case highlights that with early initiation, defined bridging goals, and multidisciplinary coordination, VA-ECMO and Impella can achieve recovery even in refractory arrhythmic cardiogenic shock. This abstract is funded by: None
Govaria et al. (Fri,) studied this question.