56: Veno-arterial Extracorporeal Membrane Oxygenation for the Management of an Atypical Course of Hypertensive Crisis: A Case Report

Introduction: Hypertensive crisis (HC) can lead to severe heart failure, which is rarely complicated by cardiogenic shock (CS). Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been a documented modality in managing other causes of CS [2], namely myocardial infarction and myocarditis, its role in HC is less studied. Case presentation: A 49-years-old male, who is hypertensive with a normal cardiac function following a remote attack of viral myocarditis, was admitted with HC and end-organ damage with acute heart failure (Table 1). Despite initial management with BiPAP and nitroglycerin infusion he rapidly progressed to extreme cardiogenic shock with profound global hypoperfusion (Figure 1). Echocardiography showed an ejection fraction (EF) of 10%. Hence, VA-ECMO was initiated for circulatory support, facilitating further management. Thereafter, coronary angiography was unremarkable, and endomyocardial biopsy showed inconclusive findings. The patient demonstrated rapid recovery and was decannulated within three days, with an EF of 42% at discharge. Conclusion: This was an atypical course of HC of unclear etiology progressing to extreme CS. In this case the rapid recovery of cardiac contractility and negative angiography may be attributed to HC-induced atypical Takotsubo cardiomyopathy which was characterized by global rather than apical hypokinesia. Moreover, the severe sympathetic overdrive exhibited by this patient raised the concern of illicit drug use, but it was not proved. The literature on CS caused by HC managed with VA-ECMO is limited. Nevertheless, one case report described a similar progression attributed to pheochromocytoma, which also demonstrated successful outcomes with VA-ECMO support. Although the profound hypoperfusion posed a risk of him crashing during cannulation, the successful implementation of VA-ECMO was crucial as a bridge for hemodynamic stabilization and further management.