An unusual cause of cardiogenic shock. How would I approach it?

From the “door to balloon” to the “shock to support”. Considering the patient’s situation when he got to the cath lab, it was prioritized to proceed with the patient’s hemodynamic stabilization through the implantation of the Impella CP device before the interventional procedure (that was performed immediately after device implantation). Although we still don’t have clinical trials that endorse this practice, several authors have confirmed significant mortality rate reductions in patients with CS using a protocol that prioritizes reducing the time elapsed from the medical contact to the implantation of the circulatory mechanical assist device and without significant increases of the time elapsed until the opening of the artery.1

Performing an emergent echocardiography was essential for diagnostic purposes and in order to guide the therapeutic attitude. We should emphasize here that the early echocardiographic assessment of a patient with CS is crucial to be able to rule out any mechanical complications and guide the implantation of a circulatory mechanical assist device.

Therapeutic scalation and upgrade. As already described when talking about the evolution of the patient, the persistence of the situation of CS led to a therapeutic scalation from the Impella CP device to ECMO. We should not forget here how important it is to perform an ongoing and thorough assessment of the patient with CS and have action protocols available and adapted to the reality of each particular center (figure 1) in order to offer the best therapeutic option in each particular case.

The characterization of the intracavitary mass. Both the echocardiographic description and the image acquired suggest the diagnosis of myxoma: 80% of them anchor to the left atrium and 16% develop embolic phenomena that are more common in large villous tumors (irregular and jelly-like, similar to the capture of the echocardiography shown).2 The main diagnostic doubt here has to do with the image of a thrombus. Different series recommend performing computed tomography scan, magnetic resonance imaging or both before establishing differential diagnosis. In this case, given the general situation of the patient, we could consider completing the study of characterization by performing one transesophageal echocardiography. Although the definitive diagnosis is always histological with the study of the surgical piece, the analysis of the fragments extracted in the thrombectomy may help.

The neurologic prognosis is key to decide the therapeutic attitude. With the data provided by the computed tomography scan (and for the lack of data from the magnetic resonance imaging and the angiography, which by the way were difficult to perform considering the situation of the patient), it does not seem plausible to perform an invasive approach using the thrombectomy. Also, the hemorrhagic risk of a patient on ECMO contraindicates thrombolysis. Therefore, we can only maintain anticoagulation, establish anti-edema measures, and make thorough assessments to determine the patient’s neurological prognosis before indicating the surgical resection of the mass.

The management of a large mass that has become occluded and then caused a severe double mitral lesion that, in turn, jeopardizes hemodynamic instability should be urgent surgical resection. However, in a patient with refractory CS on ECMO, severe systolic dysfunction due to extensive ongoing acute myocardial infarction, and diffuse cerebral edema, the risk/benefit ratio should be taken into serious consideration. Several contemporary series on the surgical management of primary tumors recommend performing minimally invasive surgery,3 although in all of them patients with large tumors or hemodynamic instability have been excluded. Therefore, if the resection of the mass is to be performed, we should choose conventional surgery, in hypothermia with total cardiopulmonary arrest, and under neurological protective measures.