REFRACTORY INVERTED TAKOTSUBO CARDIOMYOPATHY IN POLYTRAUMATIZED PATIENTS: CLINICAL FEATURES AND ADVANCED TREATMENT

Inverted tako-tsubo cardiomyopathy (ITC) is a variation of stress cardiomyopathy. It features transient myocardial dysfunction characterised by a typical contractile abnormality consisting of extensive left ventricular circumferential dyskinesia or akinesia with a hyperkinetic apex. Endogenous and esogenous catecholamine surges are believed to be the mediators of this potentially life-threatening condition. We report for the first time in this setting with refractory cardiogenic shock, the use of ECLS treatment in order to unload the heart, sustain circulation and end-organ perfusion, and promote ventricular recovery. Methods: From June 2008 to December 2011 we treated 4 adult polytrauma patients (mean age: 32.7±23.3 years, mean ISS score 59.7±13.4) with veno-arterial (v-a) ECLS for refractory cardiopulmonary failure and cardiac arrest due to ITC. We used a miniaturised ECLS device (PLS-Set, MAQUET Cardiopulmonary AG, Hechingen, Germany) and performed initially heparin-free ECMO. Results: Prior to ECMO median pH was 7.12±0.14 (6.91- 7.25), median lactate was 6.7±2.8 (10-4) mmol/l and median norepinephrine demand was 6.8 (3.5-19.6) mg/h. Refractory cardiopulmonary failure and CA complicating ITC was treated effectively with ECLS and perfusion parameters and blood flow improved rapidly within 4 h on ECLS in all patients and permits inotropic drugs weaning. 2 patients had recovered completely and 2, after post-traumatic cerebral dead determination, underwent organs explantation (ECLS as “Bridge to organs donation”). Conclusions: Initially heparin-free ECLS support can improve therapy and outcome even in disastrous polytrauma patients with coexisting/potential bleeding status and severe refractory myocardial dysfunction. Extra-corporeal life support allowed inotropic drug weaning while maintaining end-organ function and supported the patient until myocardial recovery