Abstract Body (Do not enter title and authors here):
Background
Cardiovascular disease is the leading cause of morbidity and mortality in pregnant women and accounts for 25% of maternal deaths, with cardiomyopathy accounting for 11%. Peripartum cardiogenic shock is rare. Only 18% of cases present in the antepartum period and even fewer receive mechanical circulatory support (MCS). This patient population requires a multidisciplinary approach and meticulous planning to select the best mode of MCS.

Case
A 25-year-old G1P0 was admitted at 29w3d with decompensated heart failure due to idiopathic dilated cardiomyopathy. At 15w she was asymptomatic with an EF of 20-30%, global hypokinesis, LVIDd of 6.2cm, and normal right ventricular size and function. Medical management was initiated. Admission transthoracic echocardiogram (TTE) showed an EF of 10-20%. Right heart catheterization showed RA 12 mmHg, PCWP 29 mmHg, and cardiac index (CI) of 3.4 L/min/m2 by Fick and 3.0 L/min/m2 by thermodilution. A multidisciplinary meeting including heart failure, maternal-fetal medicine, obstetrics anesthesia, and interventional cardiology was convened at 30w3d. Delivery was planned for 31w with pre-emptive placement of MCS. At 30w4d, she underwent placement of a pulmonary artery catheter (RA 13 mmHg, PCWP 24 mmHg, CI by Fick 2.0 L/min/m2) and percutaneous left axillary Impella CP with settings of P8 and flows 3-3.2 L/min. One day later, she experienced chest pain, pulmonary edema, and a drop in CI to 1.8 L/min/m2. She delivered urgently via cesarian section without complications. Impella was unable to be weaned, and she underwent expedited advanced therapies workup with orthotopic heart transplant 16 days later.

Discussion
The European Society of Cardiology recommends that MCS should be available and considered for the management of cardiogenic shock in pregnancy, but does not address specific modalities. In our case, we chose Impella CP for several reasons: the ability to place percutaneously under moderate sedation, axillary approach to allow mobility and avoid the gravid uterus, and to maximize cardiac output in the setting of low-output heart failure. This was well tolerated and allowed a safe, although urgent, delivery and was ultimately used as a bridge to transplant.

Conclusion
While risks and benefits must be tailored to each patient, early use of MCS in cardiogenic shock has been associated with improved outcomes, and pregnancy should not preclude this option.