Left Ventricular Unloading During Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in Toxic Shock: Successful ECpella Support After Massive Amlodipine Ingestion

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Abstract
Massive overdose of calcium channel blockers and angiotensin-converting enzyme inhibitors can result in refractory mixed vasoplegic and cardiogenic shock. We present a case of a 65-year-old woman with severe amlodipine and lisinopril overdose requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite improved systemic perfusion, the patient developed left ventricular distension characterized by reduced pulsatility, elevated pulmonary capillary wedge pressure, and severely depressed left ventricular function. Early placement of an Impella device for active left ventricular unloading resulted in improved hemodynamics, restoration of pulsatility, and recovery of ventricular function. The patient was successfully weaned from mechanical support with full clinical recovery. This case highlights the importance of hemodynamic-guided left ventricular unloading during VA-ECMO in toxicologic shock and supports the role of ECpella in selected patients.