Background:
Post-infarct ventricular septal rupture (PIVSR) is a rare but severe complication of myocardial infarction and is associated with high mortality. In the treatment of PIVSR, the need for urgent surgical repair to avoid acute hemodynamic compromise must be weighed against the need for delayed repair to enable the acutely necrotic myocardium to organize and to develop fibrotic tissue. We present a case of combined percutaneous mechanical circulatory support (MCS) comprising extracorporal membrane oxygenation (ECMO) and the coxial micropump Impella® CP (ECMELLA) as a bridge to definite surgical repair which allows time for left ventricular recovery prior to operative management of PIVSR.

Case Description:
A 71-year-old male presented with cardiogenic shock (CS) and inferior ST-elevation myocardial infarction after cardiopulmonary resuscitation (CPR) with quick return of spontaneous circulation (ROSC). The patient underwent emergency cardiac catheterization revealing a two-vessel disease. The completely occluded right coronary artery was percutaneously recanalized. However, CS with pulmonary oedema persisted after revascularization requiring vasopressors and inotropes. Intraprocedural transthoracic echocardiography showed pericardial hematoma with beginning of tamponade and PIVSR in the apical part of the septum with evidence of intracardial shunt and high-degree mitral regurgitation. Left and right ventricular function were impaired. The patient was subsequently transferred to cardiac surgery for emergency pericardiotomy and further circulatory and hemodynamic support as well as for closure of the PIVSR. Patient´s situation was critical with subsequent CPR with renewed ROSC. Therefore, ECMO was implanted as left ventricular mechanical support device. Due to the progressing hemodynamic deterioration with low output and severe lung congestion under ECMO, an Impella® CP was additionally inserted for left ventricular (LV) unloading. After 17 days of MCS the patient underwent Mitral valve replacement by bio prosthesis and pericardial patch repair of the PIVSR. The patient was discharged to the rehabilitation clinic 3 months after admission in improved general condition. The LVEF was still moderately impaired, but the right ventricular function had recovered completely. No residual shunt was detected.

Conclusion:
PIVSR remains a challenging situation in daily clinical practice. Standard therapy is VSR-closure and myocardial revascularization if necessary. The early and consequent combination of the Impella® CP and VA-ECMO (ECMELLA) may enable even more effective clinical stabilization and rescue high-risk patients with refractory cardiogenic shock. Our case highlights that valuable time can be gained in PIVSR by support of ECMELLA concept as bridge to- recovery to surgical repair. These measures can potentially increase operation success rate and survival of the patient.