Against the Odds: Impella-supported revival in an octogenarian with cardiogenic shock (stage E) and advanced coronary artery disease
Muthulakshmi. P1, Lydia Annie J2, Ajith Pillai3, Stalin Roy J4, Deepa Rani5
1Clinical Instructor, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
2CNO, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
3Consultant-Cardiology, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
4Consultant-Cardiology, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
5DNS, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
Summary
This case report describes the extraordinary recovery of an 85-year-old male who presented with cardiogenic shock and severe calcified triple vessel- coronary artery disease. Despite severely reduced left ventricular function (EF 15%) and end organ dysfunction, he underwent successful high-risk PCI with Impella CP support, through a multidisciplinary approach combining mechanical circulatory support, precision interventional therapy, advanced renal support, and high acuity critical care nursing. The patient’s cardiac function was restored to EF 35% & he achieved full hemodynamic stabilization. This case underscores the vital role dedicated nursing care, nutritional support and precision cardiac care play to recover a heart that completely failed.
Patient was brought to our ER with no hope of survival since he had severe left ventricular failure with very low EF and renal shut down. In addition, he had sepsis. Despite all the adverse clinical co-morbid situations, with dedicated clinical multidisciplinary care and nursing support, our team helped saving the life of this elderly gentleman. Use of percutaneous cardiac pump like Impella CP in bridging recovery is complex in cardiac emergencies and exemplifies excellence in critical care nursing.
This case was one of the most challenging yet rewarding experiences in my career. With the support of the Impella device, we were able to maintain hemodynamic stability and gradually guide the patient towards recovery. Over 29 days, I was deeply involved in his daily care-monitoring, intervening, and advocating at every step. His survival was not only a clinical success but a testimony to our teamwork, technology, and relentless critical care. This case touched me profoundly and motivated me to document it as a journal entry, to share both knowledge, and honour the journey we took together.
Introduction
Cardiogenic shock, particularly in elderly patients with multivessel CAD, carries a high risk of mortality. When compounded by sepsis and renal impairment, the prognosis is further compromised. The introduction of a device like Impella CP has redefined the hemodynamic management of such critically ill patients. This case showcases the transformational role of Impella CP in managing refractory shock in a high-risk patient who defied conventional survival odds.
The Impella CP is placed percutaneously through the femoral artery, and its microaxial flow pump-provides up to 4.0 L/min of cardiac output, directly unloading the left ventricle and enhancing systemic & coronary perfusion.
The Impella CP has 9 performance levels(P0-P9) that can be adjusted based on the patient’s hemodynamic needs
| Indications | Contraindications |
|---|---|
| Cardiogenic shock | Left ventricular thrombus |
| High-risk PCI | Mechanical aortic valve |
| Ventricular Tachycardia Ablation | Severe aortic stenosis |
| Severe peripheral arterial disease | |
| Left ventricular rupture | |
| Aortic dissection |
Case Presentation
A 85-year-old male with a medical history of systemic hypertension, known Abdominal Aortic Aneurysm, and chronic D11 wedge compression fracture presented to our emergency department. He was referred from an outside hospital where he had been intubated for Pulmonary Edema and hypotension. Initial complaints included epigastric pain and vomiting of one-day duration.
At our facility, upon arrival, he exhibited severe hemodynamic instability with a blood pressure of 80/50 mmhg on triple inotropes, HR 104/bpm, SpO2 98% on fiO2 80%. Immediate deterioration occurred leading to bradycardia requiring imaging with administration of IV adrenaline. Following stabilization, the patient was transferred directly to the cardiac catheterization laboratory.
Echo findings: EF 15%, severe LV dysfunction, moderate MR, mild AR/TR, dilated LA/LV
CAG revealed the following:
| LMCA | • 70% ostial and 99% distal stenosis |
|---|---|
| LAD | • 90% ostioproximal, 80% proximal tubular calcified stenosis |
| LCX | • 80% ostial and 70% proximal stenosis, codominant |
| RCA | • Ostial chronic total occlusion (CTO) |
Given the hemodynamic profile and CAG findings, the Impella CP device was inserted percutaneously via left femoral access. The initial Impella flow was recorded at 3.6 L/min. The patient underwent successful PCI to the LM-LAD with Rotational Atherectomy and IVUS guided stent placement, followed by drug-coated balloon (DCB) angioplasty to the LCX.
Critical care course
Patient was on triple inotropes: dopamine, dobutamine, noradrenaline support, heparin infusion, invasive ventilation, Impella support and broad-spectrum antibiotics like piperacillin-tazobactam. The patient developed AKI requiring CRRT hence initiated. Multiple blood products transfused to correct anaemia and HIT. After 5 days of Impella support, the patient was successfully extubated and Impella CP device was explanted with an improvement in EF to 35%. Subsequently, he developed bilateral pleural effusion, which necessitated two episodes of thoracentesis and albumin transfusion. Due to a rising procalcitonin level, antibiotics were escalated to colistin and minocycline. CRRT was discontinued on 11th day as the patient’s urine output began to improve and creatinine level in decreasing trends. Subsequently, SLED was initiated on alternative days. After 16 days patient was shifted to the ward.
Nurse’s role in recovery
Nurses played a pivotal role in the patient’s complete recovery. They ensure continuous hemodynamic monitoring, including MAP, CVP intake/output, response to inotropic support, and making timely adjustments to maintain stability. Ventilator management and timely care to prevent ventilator associated event, and coordination of safe extubation were critical components in airway care. During RRT, monitored fluid balance, closely observed sign of sepsis.
With the Impella device, we tracked console parameters- flow rate, purge pressures, and alarms-ensuring the device provided optimal circulatory support while preventing complications like haemolysis or limb ischemia. We closely assessed insertion sites, maintained anticoagulation protocols, and coordinated ACT monitoring and response. On mechanical ventilation, nurses were not just managing machines-they were preserving lung integrity and guiding the weaning process. They adjusted ventilator settings in collaboration with intensivists, maintained airway patency, prevented VAE through diligent care, interpreted ABG results in real time and made critical adjustments and ensured readiness before extubation. Nurses also play a key role in ensuring patient comfort, pain management, emotional reassurance and family support throughout the hospitalization.
Relapse and recovery
A few days after being shifted to the ward, the patient’s neurological status deteriorated, with a drop in GCS and hypotension. He was transferred back to ICU, where NIV was attempted but proved ineffective. Consequently, he was re-intubated, restarted on inotropic support, and underwent MRI Brain under stroke protocol, which revealed no acute infarct. The patient remained on mechanical ventilation for four days, after which he was successfully extubated. Notably, the patients procalcitonin level, which was 53.27 ng/mL during the early stage of hospitalization, gradually declined to 1.09 ng/mL by the time of recovery, indicating effective management of the septic response.
Discharge
After 29 days of intensive hospitalization, the patient was successfully discharged in a hemodynamically stable condition. He was ambulatory with minimal assistance and discharged on a structured cardiac medication regimen.
Discussion
This case exemplifies the life-saving role of percutaneous mechanical circulatory support in patients with high risk coronary disease and cardiogenic shock. The Impella CP device, unloading the left ventricle, promotes myocardial recovery by improving coronary perfusion and reducing wall stress. In elderly patients, where surgical revascularization is often high-risk or contraindicated, Impella-supported PCI offers a viable alternative.
Our patient presented with SCAI Stage E shock, where mortality exceeds 80% in most cohorts. The timely insertion of Impella and completion of high-risk PCI were critical turning points. Beyond technology, comprehensive critical care nursing- including infection surveillance, hemodynamic titration, sedation management, renal support coordination, and early rehabilitation contributed to recovery. The coordination between intensivists, cardiologists, nephrologists and nurses were pivotal.
Notably, the patient successful extubation twice during hospitalization, reversal of AKI, resolution of sepsis and EF improvement underlines the synergy between interventional precision and continuous high-acuity nursing vigilance.
| Details | This case | Reference case |
|---|---|---|
| Patient profile | 85yr old male — Cardiogenic shock + NSTEMI | 28yr old male — Cardiogenic shock + myocarditis |
| Medical history | AAA, SHTN, D11 fracture | Nil |
| Presenting complaints | Epigastric pain & vomiting — 1 day | Chest discomfort, shortness of breath, near syncope episode |
| Initial vitals | BP: 80/50 mmHg on triple inotropes, HR: 104 bpm, SpO2: 98% on FiO2 80% | HR: 125 bpm, BP: 75/40 mmHg, RR: 30 bpm, SpO2: 89% on room air |
| Device | Impella CP | Impella CP |
| CAD | Calcific left main with Triple vessel | Normal coronary arteries |
| Impella explanation | Day 6 | Day 7 |
| EF on discharge | 35% | 55% |
| Recovery period | 29 days | 10 days |
Recovery period 29 days were attributed to several factors like advanced age and severe pre-existing comorbidities
Conclusion
Survival from cardiogenic shock & sepsis in the setting of severe CAD and critical LV dysfunction is rare, particularly in elderly. This case reinforces the role of Impella CP as a hemodynamic bridge, and exemplifies how advanced cardiac nursing-rooted in vigilance, teamwork, and evidence-based protocols can turn critical moments into milestones of recovery.
