A 68 year-old man with a history of hypertension, diabetes mellitus and heart transplantation due to ischemic cardiomyopathy presented with 2 days of fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, he weighed 78 kg (body surface area 1.9m
2), he was tachycardic, hypotensive (mean arterial pressure [MAP] 57 mmHg) and hypoxic with cool extremities, consistent with CS. Dopamine was initiated at 10mcg/kg/min. Transthoracic echocardiogram (TTE) showed new severe biventricular dysfunction with LV ejection fraction of 15%. He was brought to the cardiac catheterization lab for endomyocardial biopsy and right heart catheterization (RHC) which demonstrated elevated filling pressures (right atrial pressure (RAP) 22 mmHg, mean pulmonary artery pressure (mPAP) 33 mmHg, pulmonary capillary wedge pressure (PCWP) 36 mmHg, pulmonary artery saturation (PA sat) 43%, and Fick cardiac index 1.5 L/min/m
2). An IABP was inserted via the left femoral artery. Balloon counterpulsation provided minimal improvement in his hemodynamic profile (PA sat 38%). As a result, VA-ECMO was initiated via the right femoral artery and vein with flow of 3.0 L/min (1.6 L/min/m
2). Repeat TTE demonstrated aortic valve (AV) opening with each cardiac cycle. With placement of the IABP on standby Additional file
1: Video 1 (video clip 0:03), the AV no longer opened. Reinitiation of balloon counterpulsation resulted in resumed AV opening with each beat Additional file
1: Video 1 (video clip 0:17). Repeat hemodynamics showed MAP 65 mmHg, RAP 10 mmHg, mPAP 27 mmHg, PCWP 22 mmHg and PA sat 56%, dopamine was discontinued. He was treated for presumed acute allograft rejection with methylprednisolone, thymoglobulin, intravenous immunoglobulin and plasmapheresis. With this his hemodynamics improved; VA-ECMO was removed after 11 days and IABP was removed 3 days later (hemodynamics: RAP 13 mmHg, mPAP 32 mmHg, PA sat 53%). Repeat TTE showed improvement in allograft function. However, he developed an
Enterobacter aerogenes pneumonia and rapidly fatal septic shock.