Axillary microaxial flow pump support for stepwise source control and bridge to durable left ventricular assist...

Cardiac device-related infective endocarditis complicated by end-stage heart failure poses a major therapeutic challenge because complete hardware removal is essential, whereas transvenous lead extraction may be poorly tolerated in patients with severe ventricular dysfunction and shock. We report a 53-year-old man with long-standing dilated cardiomyopathy and cardiac resynchronization therapy-defibrillator infection who presented with methicillin-sensitive Staphylococcus aureus bacteremia, pocket infection, respiratory failure, acute kidney injury, and a clinical presentation consistent with mixed septic-cardiogenic shock. Transthoracic echocardiography showed severe left ventricular dilatation and an ejection fraction of 10%. Because immediate extraction of a 17-year-old defibrillator lead was considered extremely high risk, an Impella 5.5 was implanted via the right subclavian artery, and surgical pocket drainage was performed as initial source control. After hemodynamic stabilization and reduction of vasoactive requirements, complete transvenous extraction of all leads was performed on hospital day 6 under ongoing Impella 5.5 support and cardiovascular surgical backup. During defibrillator lead traction, pulmonary artery pressure transiently decreased, but sustained systemic hemodynamic collapse did not occur. Following prolonged intravenous antibiotic therapy, blood cultures remained negative, renal function recovered sufficiently to discontinue continuous hemodiafiltration, and the patient was transferred to an advanced heart failure center. Durable left ventricular assist device implantation was subsequently performed successfully. This case suggests that axillary Impella 5.5 support may provide a stabilizing platform for staged source control, high-risk lead extraction, end-organ recovery, and bridge to durable mechanical circulatory support in carefully selected patients.