Successful Use of Impella Support to Treat Cardiogenic Shock Secondary to Takotsubo Cardiomyopathy Owing to Alcohol Withdrawal

Takotsubo cardiomyopathy associated with alcohol withdrawal is rare in Japan, and its management in such cases using percutaneous left ventricular assist devices (Impella; Abiomed, Japan) is not common. This report describes the treatment of a patient with cardiogenic shock resulting from alcohol withdrawal-induced Takotsubo cardiomyopathy using Impella support. A female patient in her 60s with a history of alcohol dependence presented to the emergency room with fever and convulsions. Upon arrival, she developed status epilepticus requiring intubation and mechanical ventilation. Subsequently, her blood pressure decreased, leading to shock. On day two of hospitalization, laboratory tests revealed elevated creatine kinase and troponin I levels, and an electrocardiogram demonstrated ST elevation. Transthoracic echocardiography demonstrated a reduced left ventricular ejection fraction of approximately 30-40%. Coronary angiography revealed no significant stenoses. Left ventricular angiography indicated akinesis in the mid-ventricle, with hyperkinesis at the base and apex. Based on the Mayo Clinic criteria, the patient was diagnosed with mid-ventricular Takotsubo cardiomyopathy. Myocardial biopsy ruled out myocarditis. Furthermore, CT revealed no obvious adrenal tumor, and pheochromocytoma was also ruled out. No evidence of alternative causes such as emotional stressors, severe infection, or exogenous catecholamine administration was found; thus, alcohol withdrawal was identified as the likely underlying trigger. The hemodynamic data showed a left ventricular pressure of 99/10 mmHg, an aortic pressure of 79/58 mmHg, with a significant intraventricular pressure gradient, and an elevated left ventricular end-diastolic pressure (LVEDP) of 33 mmHg. Right heart catheterization performed simultaneously revealed a pulmonary artery pressure of 46/31/37 mmHg, a pulmonary capillary wedge pressure of 32/30/29 mmHg, a cardiac output (CO) of 3.16 L/minute, and a cardiac index of 2.16 L/minute/m². The patient was in cardiogenic shock and required mechanical circulatory support. Given the presence of an elevated intraventricular pressure gradient and LVEDP, we judged that the Impella device would provide adequate circulatory support while unloading the left ventricle to reduce LVEDP and wall stress without exacerbating the left ventricular outflow tract gradient. An Impella CP was inserted and initiated at a support level of P8. Concurrently, antiepileptic therapy was administered for status epilepticus. On hospital day three, the LVEDP decreased while CO and cardiac power output (CPO) improved, indicating effective left ventricular support. While targeting a mean arterial pressure >65 mmHg, CPO >0.6 W, pulmonary artery pulsatility index >0.9, and lactate <2.0 mmol/L as reference parameters, the support level was gradually reduced. On hospital day five, CO recovered to 5.0 L/minute, and the Impella support level was successfully weaned to P3, allowing for device removal. The patient was discharged from the intensive care unit on hospital day 12. This case suggests that Impella support may provide appropriate hemodynamic stabilization in Takotsubo cardiomyopathy complicated by cardiogenic shock. However, as this is a single case report, further accumulation of similar cases is warranted in the future.