Use of CentriMag for refractory cardiogenic shock in a puerperal woman: case report

ABSTRACT CONTEXT: Heart failure in Brazil is a major public health problem and, even with advances in treatment, it still presents high morbidity and mortality. As a treatment option, mechanical circulatory assist devices (MCADs) have greatly increased in importance over the last decade. CASE REPORT: This report concerns a case of refractory cardiogenic shock due to acute myocarditis in a 35-year-old puerperal female patient who presented with retrosternal pain, fatigue and dyspnea. At the hospital, she was diagnosed with myocarditis. There was no improvement in perfusion even after receiving dobutamine, intra-aortic balloon passage (IAB) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, it was decided to implant a MCAD (CentriMag). During hospitalization, recovery from the bi-ventricular dysfunction was achieved. The CentriMag device was removed 10 days after it had been implanted, and the patient was discharged after another 8 days. The myocarditis was proven to be due to the Coxsackie virus. CONCLUSIONS: The decision to implant a MCAD should be individualized, as patient profiles do not always match the indications in the guidelines and protocols. In this study, clinical discussion of the case among the medical and multi-professional teams was essential in order to be able to successfully reverse the patient’s severe clinical condition without sequelae, through using a CentriMag implant.


INTRODUCTION
Worldwide, there were approximately 26 million people with heart failure in 2014. This therefore represents a major public health problem. 1 In Brazil, the scenario is not different and, even with advances in treatment, heart failure still presents high morbidity and mortality. The incidence of heart failure in Brazil is 199 cases per 100,000 person-years, and the one-year mortality rate is 24.5% (95% confidence interval, CI, 19.4%-30.0%). 2 Recent data from the Department of Information Technology of the Brazilian National Health System (DATASUS) have shown that in Brazil the number of heart failure deaths was 27,461 just in 2017. 3 As a treatment option, mechanical circulatory assist devices (MCADs) have greatly increased in importance over the last decade. Although there are solid guidelines for indication of MCAD implantation, 4 some particular cases still need to be studied, such as cases of refractory cardiogenic shock due to myocarditis. The objective of this case report was to present a case of refractory cardiogenic shock due to acute myocarditis in a young puerperal woman.
A 35-year-old married female patient who was in the early puerperal period (childbirth in April 2019) sought emergency assistance with flu symptoms that she had had for approximately six days. At the emergency room, she was diagnosed with tonsillitis and was treated with azithromycin and prednisone. In the absence of symptom improvement, she presented retrosternal pain, fatigue and dyspnea. In a new medical evaluation, markers for myocardial necrosis were examined, with positive results, suggesting a diagnostic hypothesis of myopericarditis.
After admission to the coronary unit, she presented signs of low cardiac output with precordial pain, nausea and peripheral perfusion and was then referred to the advanced heart failure unit. She used vasoactive drugs (VAD), but without improvement in perfusion and clinical

ABSTRACT
CONTEXT: Heart failure in Brazil is a major public health problem and, even with advances in treatment, it still presents high morbidity and mortality. As a treatment option, mechanical circulatory assist devices (MCADs) have greatly increased in importance over the last decade. CASE REPORT: This report concerns a case of refractory cardiogenic shock due to acute myocarditis in a 35-year-old puerperal female patient who presented with retrosternal pain, fatigue and dyspnea. At the hospital, she was diagnosed with myocarditis. There was no improvement in perfusion even after receiving dobutamine, intra-aortic balloon passage (IAB) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, it was decided to implant a MCAD (CentriMag). During hospitalization, recovery from the bi-ventricular dysfunction was achieved. The CentriMag device was removed 10 days after it had been implanted, and the patient was discharged after another 8 days. The myocarditis was proven to be due to the Coxsackie virus. CONCLUSIONS: The decision to implant a MCAD should be individualized, as patient profiles do not always match the indications in the guidelines and protocols. In this study, clinical discussion of the case among the medical and multi-professional teams was essential in order to be able to successfully reverse the patient's severe clinical condition without sequelae, through using a CentriMag implant.
presentation. After her case has been discussed by the team, it was decided to perform intra-aortic balloon (IAB) passage. Because of progression of dysfunction and worsening of her general condition, it was decided to install peripheral venoarterial extracorporeal membrane oxygenation (ECMO). The patient maintained the signs of low output and low flow in ECMO, in addition to poor perfusion in the right lower limb after cannulation. It was therefore decided to replace the ECMO with a ventricular assist Eight days after implant removal (July 19, 2019), the patient was discharged from the hospital with preserved bi-ventricular function ( Figure 2). Currently, the patient is in outpatient follow-up without complaints, presenting good quality of life and preserved heart function (EF 62%).

DISCUSSION
In this case report, we present a peculiar case of a 35-yearold puerperal woman who progressed with significant worsening of cardiac function within a few hours, even with passage of an IAB and ECMO. The decision to install a CentriMag device in this patient was crucial for enabling myocardial recovery and significant improvement of cardiac output. Reports involving use of CentriMag to treat heart failure in the postpartum period remain rare. Table 1 shows the results from a systematic search for similar studies using the PubMed and EMBASE databases.
Temporary mechanical circulatory assist devices (MCADs) are important for re-establishing the hemodynamic condition and should be indicated individually. In addition, they serve as an aid for decision-making up to the point of defining the approach to be taken in cases where immediate hemodynamic support is required (as a bridge to decision); or for recovery of ventricular function in cases of acute myocardial infarction (as a bridge to recovery); or as hemodynamic support and clinical stabilization of patients in a severe condition who are in a transplant queue (as a bridge to transplantation). 4 It is known that IAB is widely used as the first option for treating heart failure, 5 but in some cases in which refractory cardiogenic shock occurs, ECMO is an excellent and rapid option. CentriMag provides a temporary option for ventricular function support until the myocardium recovers, 6 thus preventing low output from leading the heart to irreversible cellular conditions.

CONCLUSIONS
The decision to implant a MCAD should be individualized, as patient profiles do not always match the indications in the guidelines and protocols. In this study, clinical discussion of the case among the medical and multi-professional teams was essential in order to be able to successfully reverse the patient's severe clinical condition without sequelae, through using a CentriMag implant.