Breast cancer surgery performed on full ECMELLA support after HER2-drug cardiogenic shock

A case report published in the journal Cardio-Oncology describes a woman with HER2-positive breast cancer who developed severe left ventricular failure and refractory cardiogenic shock shortly after receiving dual HER2 blockade with trastuzumab and pertuzumab, and who then underwent curative removal of her breast tumour while supported by a combined mechanical circulation setup known as ECMELLA.

Trastuzumab and pertuzumab are key agents in the treatment of HER2-positive breast cancer, but they may cause left ventricular dysfunction. According to the report’s authors, fulminant cardiotoxicity leading to cardiogenic shock is extremely uncommon, and management strategies for this complication remain poorly defined. The published account is a single-patient case report, released as a peer-reviewed accepted manuscript with a permanent DOI, and its conclusions are correspondingly limited to what happened in this one patient.

In the case described, haemodynamic stabilisation was first attempted with inotropes and vasopressors. When that proved insufficient, clinicians implanted a percutaneous left ventricular assist device, the Impella CP. Owing to persistent circulatory collapse, the team then initiated veno-arterial extracorporeal membrane oxygenation, or VA-ECMO, and combined it with the Impella device. This dual configuration, in which the ECMO circuit supports the circulation while the Impella unloads the left ventricle, is referred to as an ECMELLA configuration.

During this period of full mechanical circulatory support, the patient underwent surgical removal of the breast tumour after multidisciplinary evaluation. The report states that progressive myocardial recovery followed, allowing complete weaning from mechanical circulatory support. She achieved sustained haemodynamic stability, with a left ventricular ejection fraction of approximately 45 percent while on standard heart failure therapy.

The authors present the case as an illustration of the potential reversibility of a presumed HER2-blocker-induced fulminant cardiomyopathy. They also highlight the role of timely escalation of mechanical circulatory support and coordinated cardio-oncology care, which in this instance extended to successful oncologic surgery being carried out while the patient remained on ECMELLA support. As the authors themselves frame it, the case underscores what coordinated multidisciplinary management may make possible in this rare and poorly defined clinical situation, rather than establishing a general treatment standard.

Subject of Research: A case report of curative breast cancer surgery performed during combined ECMO and Impella mechanical circulatory support for severe cardiotoxicity from trastuzumab and pertuzumab.

Article Title: Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock

Article References: d’Aiello, A., Pedicino, D., Franceschini, G., D’Archi, S., Di Guglielmo, E., Paris, I., Massetti, M., Scapigliati, A., Antoniucci, M. E., Burzotta, F., Trani, C., Aurigemma, C., Lunardi, M., Luzi, G., D’Avino, E., Sbaraglia, F., & Sanna, T. (2026). Curative breast cancer surgery during full ECMELLA support for trastuzumab/pertuzumab related cardiogenic shock. Cardio-Oncology. https://doi.org/10.1186/s40959-026-00595-8

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DOI: 10.1186/s40959-026-00595-8

Keywords: cardio-oncology, HER2-positive breast cancer, trastuzumab, pertuzumab, cardiogenic shock, cardiotoxicity, ECMELLA, VA-ECMO, Impella, mechanical circulatory support, left ventricular dysfunction, case report