A combination of veno-arteriovenous ECMO and Impella (VAVEcpella) as a rescue strategy for severe streptococcal toxic shock syndrome with cardiopulmonary failure: A case report

Abstract

Rationale: Streptococcal toxic shock syndrome (STSS) is an invasive Streptococcus pyogenes infection characterized by hypotension and multiple organ failure with rapid progression and high mortality. Although extracorporeal membrane oxygenation (ECMO) has been used in adults with STSS, mortality remains high and optimal mechanical circulatory support is controversial. Veno-arterial ECMO has specific complications in severe cardiopulmonary failure, including differential hypoxia and increased left ventricular end-diastolic pressure due to retrograde flow. Patient concerns: A 51-year-old man presented to the emergency department with fever and dyspnea, progressing rapidly from an initially diagnosed upper respiratory tract infection to severe respiratory distress and refractory shock requiring oxygen supplementation and vasopressor support. Diagnoses: The patient was diagnosed with STSS, which manifested as septic shock with severe cardiopulmonary compromise. Interventions: We implemented a combined approach using veno-arteriovenous ECMO (V-AV ECMO) and Impella CP® support (veno-arteriovenous extracorporeal membrane oxygenation and Impella [VAVEcpella]). This strategy provided oxygenated blood to the right heart while achieving left ventricular unloading. This was done in conjunction with appropriate antibiotic therapy and source control measures. Outcomes: The novel VAVEcpella approach successfully supported the patient through severe cardiopulmonary failure secondary to STSS-induced septic shock. To our knowledge, this is the first reported case of VAVEcpella implementation specifically for the management of STSS. Lessons: The VAVEcpella approach (combined V-AV ECMO and Impella support) may represent a viable rescue strategy for patients with severe cardiopulmonary failure secondary to septic shock, such as STSS, where traditional support methods have shown limited success.