Novel method for diagnosing takotsubo syndrome with left ventriculography using a microaxial flow pump in temporary surgical mode in a patient with cardiogenic shock: a case report.

Background: It is reasonable to introduce a microaxial flow pump (Impella) before coronary angiography and left ventriculography (LVG) to prioritize treating tissue hypoperfusion in patients with takotsubo syndrome (TTS) and refractory cardiogenic shock. However, left ventricular (LV) unloading by an Impella device might prevent contrast media from filling the left ventricle, making it difficult to evaluate LV wall motion abnormalities during LVG.

Case summary: A 76-year-old female with ST elevations in I, II, aVL, and V1-6 on electrocardiography and severe LV dysfunction on echocardiography immediately received circulatory support with Impella CP to treat refractory cardiogenic shock. Subsequent coronary angiography showed no significant stenosis. Biplane LVG was performed using an additional pigtail catheter inserted into the left ventricle while the pump catheter remained there in temporary surgical mode, which was able to protect the motor because the purge system remained active while the pump was stopped. Left ventriculography in temporary surgical mode revealed apical ballooning with a mismatch between epicardial coronary artery perfusion and LV contraction without compromised haemodynamics. The patient was diagnosed with TTS.

Discussion: Coronary angiography and LVG are considered essential diagnostic tools to confirm TTS and exclude acute myocardial infarction. Left ventriculography with Impella temporarily set to surgical mode was able to clearly evaluate LV wall motion abnormalities without affecting haemodynamics. This case highlights that it is perfectly acceptable to prioritize Impella insertion over coronary angiography and LVG in patients with refractory cardiogenic shock in whom the differentiation between TTS and acute myocardial infarction has not yet been made.