Left ventricular perforation following impella® CP placement in a resuscitated STEMI patient with cardiogenic shock: a rare complication and case report

Background: The use of mechanical circulatory support (MCS) for acute haemodynamic stabilization in cardiogenic shock has increased over the past decade. Impella® heart pumps (Abiomed) are intravascular microaxial blood pumps designed to provide temporary MCS during high-risk percutaneous coronary intervention (HRPCI) and the management of cardiogenic shock. However, despite their increasing use, there are limited randomized clinical trials to support the benefits of the therapy and growing concern regarding complication rates. The objective of this report is to present a rare case of a left ventricular perforation after Impella® CP placement in a resuscitated patient after ST-elevation myocardial infarction (STEMI). Case summary: We present the case of a 54-year-old patient who suffered an out-of-hospital cardiac arrest (OHCA) due to STEMI and was successfully resuscitated. Due to persistent cardiogenic shock, Impella® CP support was initiated. The clinical course was complicated by recurrent and refractory ventricular fibrillation (VF), requiring multiple resuscitations in the intensive care unit (ICU). These resuscitative efforts, combined with friable necrotic myocardial tissue from the infarction, contributed to a left ventricular perforation and dislocation of the Impella device in the pericardium. To stabilize the patient, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated, followed by transfer to the cardiac surgery department. Despite the severity of the complications, the Impella was successfully explanted and replaced with a transaxillary Impella® 5.5 pump without the need for open-heart surgery. Extubation was achieved few days later, and the patient demonstrated progressive clinical recovery with successful weaning from the ECMO as well as the Impella 5.5. Conclusion: This case demonstrates that profound myocardial fragility following resuscitated STEMI may be a critical co-factor for Impella-related perforation, underscoring the necessity for extreme procedural vigilance and timely, multidisciplinary management in patients requiring mechanical circulatory support.