Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

Trastuzumab and pertuzumab are key agents in the treatment of HER2-positive breast cancer but may cause left ventricular (LV) dysfunction. Fulminant cardiotoxicity leading to cardiogenic shock is extremely uncommon, and management strategies remain poorly defined. We describe a patient with HER2-positive breast cancer who developed severe LV failure and refractory cardiogenic shock shortly after dual HER2 blockade. Hemodynamic stabilization was initially attempted with inotropes and vasopressors, followed by percutaneous left ventricular assist device (Impella CP) implantation. Owing to persistent circulatory collapse, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated and combined with Impella support (ECMELLA configuration). During ECMELLA, the patient underwent surgical removal of the breast tumour after multidisciplinary evaluation. Progressive myocardial recovery allowed complete weaning from mechanical circulatory support (MCS). She achieved sustained hemodynamic stability, with an LV ejection fraction (LVEF) of approximately 45% under standard heart failure therapy. This case underscores the potential reversibility of a presumed HER2-blocker-induced fulminant cardiomyopathy and highlights the role of timely MCS escalation and coordinated cardio-oncology care, even allowing successful oncologic surgery during ECMELLA support.