ABSTRACT
A 19-year-old man was centralized in our cardiac intensive care unit due to refractory cardiogenic shock and multiorgan failure (MOF).At the admission he presented with hypotension, tachycardia and severe metabolic acidosis (pH 6.8,lac 18),ECG showed sinus tachycardia with left branch block, the echocardiography showed dilated left ventricle,with normal thickness (no edema), EF 15% with diffuse hypokinesia and right ventricle dysfunction (TAPSE 12 mm,S' 8,FAC 25%).He had elevated levels of transaminases and severe reduction of liver synthesis (INR 3.7,ATIII 19%,fibrinogen 53 mg/dl). From patient's history emerged a familiarity for an unspecific heart disease and some months ago fever (SARS-CoV2 tests negative) and progressive symptoms of right ventricle heart failure appeared.After the admission the patients was supported with ino-vasopressors,then bicarbonate and coagulation factors were administered and ventilation was optimized. Patient had a cardiogenic shock stage D and MOF,therefore a mechanical circulatory support (MCS) would have been indicated but from heart team discussion emerged fear of vascular complications or systemic bleeding during MCS support,due to the severe alteration of the caogulative state. Furthermore there were no adjunctive indications for veno- arterial ECMO support such as severe hypoxemia or ventricular arrhythmias.Multiparameter monitoring continued and two femoral sheath were positioned for a possible MCS implantation. After few hours systemic pressure stabilized. with norepinephrine and dobutamine, diuresis was adequate, blood gas improved, lactate reached 24 mmol/l and then slowly decrease for a concomitant liver dysfunction. After levosimendan infusion right ventricle contractility improved and after 5 days the patient was extubated. Acute or subacute myocarditis was excluded because of cardiac MRI did not show edema but bilateral fibrosis, myocardial biopsy showed little fibrosis,no lympho-monocitary infiltrates,no viral inclusion,no accumulation. Serological tests excluded viral hepatitis, Chagas disease, ceruloplasmin levels were normal. The patient was discharged after execution of check-list for heart transplantation, moreover CRT-D was implanted. Genetical exams are ongoing. Conclusion: Rapid patient centralization and discussion with heart team,assessing hemodynamic laboratory and metabolic parameters,allowed us to avoid an early MCS implantation and to observe the positive effects of pharmacological and support therapy (Figure Presented).