VA-ECMO and Impella provided a bridge to cardiac recovery in a 49-year-old man who developed refractory cardiac arrest during treatment for super-refractory status epilepticus associated with neurosyphilis. Gutfreund and colleagues describe combined extracorporeal circulatory support and left ventricular unloading after severe conduction disturbances progressed to pulseless electrical activity and asystole. The case illustrates rescue support for potentially reversible cardiac dysfunction, while leaving uncertainty about which medications or interactions caused the arrest.
Clinical Presentation and the Underlying Diagnosis
The patient presented with repeated generalized tonic-clonic seizures despite treatment with valproic acid. He had developed epilepsy approximately six months earlier. Prehospital clinicians administered midazolam and levetiracetam, and his Glasgow Coma Scale score was six on arrival. Electroencephalography subsequently demonstrated nonconvulsive status epilepticus, with only a brief response to clonazepam.
Brain magnetic resonance imaging showed prominent frontal atrophy and hemosiderin deposition. Cerebrospinal fluid demonstrated lymphocytic pleocytosis, and serum and cerebrospinal fluid testing supported neurosyphilis. Initial echocardiography was unremarkable, and imaging did not identify syphilitic aortitis or aneurysms. A history obtained later revealed a previous admission for status epilepticus and syphilis, followed by incomplete treatment.
Escalating Seizure Therapy and Cardiac Warning Signs
Persistent seizure activity required intubation and anesthetic therapy with propofol and midazolam. Lacosamide was added, and intravenous penicillin G was started for neurosyphilis. The admission electrocardiogram showed sinus bradycardia; subsequent recordings demonstrated T-wave inversions, QTc prolongation, and intermittent junctional escape rhythms as vasopressor requirements increased.
Lacosamide was discontinued because of suspected conduction toxicity. Nevertheless, recurrent nonconvulsive seizures during sedation reduction led to further treatment escalation, including perampanel, additional midazolam, and esketamine. Thiopental was then administered to obtain burst suppression. Wide-complex tachycardia followed immediately, and electrical cardioversion attempts were unsuccessful. Amiodarone converted the rhythm to narrow-complex tachycardia with intermittent complete atrioventricular block.
Cardiac arrest developed despite increasing vasoactive support. Mechanical cardiopulmonary resuscitation was initiated, with subsequent pulseless electrical activity and periods of asystole. The report describes a prolonged arrest but does not provide a precise low-flow interval; an exact resuscitation duration should therefore not be inferred.
Why VA-ECMO and Impella Were Combined
Peripheral VA-ECMO was established through right femoral arterial and venous access. Echocardiography showed severe left ventricular dysfunction without demonstrable ejection. An Impella CP was subsequently inserted through the left femoral artery to unload the left ventricle. Coronary angiography showed no obstructive coronary artery disease.
The rationale for combined support was physiological: VA-ECMO could maintain systemic perfusion while the heart was unable to sustain circulation, whereas the transvalvular microaxial pump provided an unloading route for the non-ejecting left ventricle. In this setting, arterial ECMO support can increase ventricular afterload, and absent ejection raises concern about distension, pulmonary congestion, and blood stasis. These concerns explain the intervention; they do not establish that every patient receiving VA-ECMO requires Impella support.
The combined approach, commonly called ECPELLA or ECMELLA, stabilized circulation and was accompanied by improvement in markers of systemic hypoperfusion. The article does not supply detailed ECMO flow targets, cannula sizes, anticoagulation management, or Impella performance settings. Those operational details cannot be reconstructed from the reported outcome.
Recovery During Mechanical Circulatory Support
Several additional interventions occurred during recovery. Continuous venovenous hemodiafiltration was initiated with the stated aim of facilitating drug clearance, and the team used hyperinsulinemic euglycemic therapy adapted from beta-blocker toxicity protocols. Antibiotics were changed from benzylpenicillin to ceftriaxone. Persistent asystole with isolated P waves prompted temporary transvenous pacing on day five.
A junctional rhythm and then sinus rhythm returned on days six and seven, accompanied by recovering left ventricular function. The case narrative reports removal of VA-ECMO and Impella on day eight after approximately five days of mechanical support. Echocardiography on day ten showed normal left and right ventricular function. The accompanying support table is not fully consistent with the narrative on removal timing, so these dates should be read as the authors’ reported clinical sequence rather than a precisely reconciled device log.
Cardiac recovery preceded complete neurological and functional recovery. The patient required tracheostomy, feeding-tube placement for severe dysphagia, and prolonged rehabilitation. After 28 days in intensive care and a further two weeks on the neurology ward, he transferred to neurorehabilitation. Later progress included independent walking, self-care, and substantial cognitive improvement; he returned to his home country for continued rehabilitation four months after admission.
Suspected Drug Interactions: Plausible, but Unproven
The authors propose that overlapping effects of antiseizure medications and anesthetics on cardiac ion channels contributed to the conduction abnormalities and myocardial depression. Lacosamide had been stopped approximately 30 hours before the arrest, but residual exposure was considered potentially relevant. The immediate deterioration after thiopental strengthened suspicion of a medication-related event in a patient already receiving multiple agents.
Temporal association and biological plausibility do not prove causation. This case cannot determine the contribution of each medication, quantify an interaction, or exclude every competing explanation. Post-arrest myocardial dysfunction may also have influenced the subsequent course. Similarly, recovery during renal replacement therapy and insulin treatment does not establish that either intervention accelerated clearance of the responsible agents or improved survival.
Relevance for Perfusion Teams and Evidence Limitations
For perfusion and critical care teams, the report connects three important observations: evolving electrical instability during intensive seizure treatment, potentially reversible circulatory failure, and a non-ejecting ventricle after initiation of VA-ECMO. It also demonstrates why neurological prognosis and recovery require longitudinal assessment rather than being equated with early cardiac recovery.
This is a single uncontrolled case with multiple simultaneous treatments and no comparator. It cannot establish a survival advantage for combined support over VA-ECMO alone, define selection criteria, or provide a standard treatment algorithm. Additional vascular access and a second mechanical device also introduce potential bleeding, vascular, and hemolysis risks that must be weighed in individual cases. The central contribution is a documented example of rescue and recovery, together with a hypothesis about medication interactions that requires further study.
The authors report no financial support for the submitted work and no relevant financial or other conflicts of interest. Their consent statement indicates that consent for treatment and open-access publication was obtained or waived.
Original Article
Gutfreund D, Loretz L, Bloch A, Diem L, Albrecht S, Bossard M. Super-Refractory Status Epilepticus (SRSE) Secondary to Neurosyphilis Complicated by a Prolonged Drug-Induced Cardiac Arrest Successfully Bridged With Extracorporeal Membrane Oxygenation (ECMO) and Impella®: A Case Report. Cureus. 2026;18(10):e118335. doi:10.7759/cureus.118335.
This independently written educational summary accompanies the unchanged open-access source PDF, published under CC BY 4.0. The cover is an AI-generated editorial illustration.
