Identification of patients with cardiogenic shock and right ventricle (RV) dysfunction who may require biventricular rather than isolated left ventricular (LV) support remains challenging. In this setting, rigorous hemodynamic evaluation of biventricular contractility and load during initiation of LV support guides therapy. We now report a novel approach to assess biventricular pressure-volume loops in a patient receiving Impella 5.5 support for heart failure and shock.

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Background: Use of the Impella 5.5 trans-valvular axial flow pump is increasing among patients with heart failure and cardiogenic shock (HF-CS) as a bridge to advanced therapies or myocardial recovery. The effect of trans-valvular left ventricular (LV) unloading on biventricular hemodynamics remains poorly understood. Methods: Seven patients with HF-CS underwent Impella 5.5 placement. A conductance catheter was placed first in the right ventricle (RV) then the LV to record pre-support pressure-volume loops. After insertion of the Impella 5.5, LV then RV loops were recorded within 15 minutes of device activation. Pulmonary artery catheter indices were recorded before and after Impella 5.5 activation. Results: Compared to baseline values, Impella 5.5 activation significantly decreased LV systolic and diastolic pressures as well as LV dP/dt(max) (Figure and Table). Impella 5.5 also significantly decreased right atrial, pulmonary (systolic/diastolic/mean) and RV diastolic pressures. Both LV and RV pressure-volume area and stroke work were not significantly changed with acute LV unloading. Conclusions: Trans-valvular unloading with an Impella 5.5 decreases biventricular filling pressures and reduces pulmonary pressures. These findings suggest that percutaneous LV unloading in patients with acute decompensated heart failure and cardiogenic shock may improve RV performance.