Potential systemic inflammatory reactions attributable to mechanical circulatory support in a patient with acute myocardial infarction complicating cardiogenic shock: a case report

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Background: Mechanical circulatory support (MCS) is an advanced therapy in cardiogenic shock (CS). While MCS improves worsened hemodynamic condition in patients exhibiting CS, several mechanistic studies reported that MCS may induce activation of inflammatory pathways, which could cause systemic inflammatory response syndrome (SIRS). Here we report a case of CS exhibited continuing high fever after the removal of MCS. This case is unique in terms of detailed evaluation of causes for high fever. Serial imaging and autopsy provided clinical insights into MCS-related inflammatory reactions. Case Description: A 60-year-old man presented acute myocardial infarction complicating CS [Society for Cardiovascular Angiography and Interventions (SCAI) shock stage = D]. He had a history of type 2 diabetes mellitus and chronic kidney disease. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella 5.5 were used to improve hemodynamic condition after the successful completion of primary percutaneous coronary intervention for the occlusion of left main trunk. Since left ventricular ejection fraction improved (15%), VA-ECMO was removed on Day 14. After its removal, body temperature rose from 37.0 to 38.5 ℃, accompanied by declines of systemic vascular resistance (from 1,990 to 1,380 dyne-sec/cm5), systolic blood pressure (from 81 to 45 mmHg) and mixed venous oxygen blood saturation (from 74% to 53%). Furthermore, he exhibited an elevated C-reactive protein (CRP) level (19.4 mg/dL). Full-body computed tomography (CT) on day 14 did not show any infectious causes. Blood, urine and sputum cultures on day 16 were negative. Despite antibiotic escalation with the use of noradrenaline and vasopressin, shock status further worsened and then he was deceased on day 18. An autopsy did not reveal any evidence causing continuing high fever after the removal of VA-ECMO. Conclusions: Our case exhibited continuing high fever and elevated CRP level. Given that serial CT and autopsy did not find any infectious signs, MCS might cause SIRS, ultimately resulting in further deterioration of hemodynamic conditions. In patients treated with MCS, it is clinically important for physicians to recognize MCS-related SIRS as a potential cause of high fever. Early differential diagnosis and the removal of MCS have to be considered for the management of MCS-related systemic inflammatory reaction.

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