Biventricular Impella use in pediatric patients with severe graft dysfunction from acute rejection after heart transplantation

Abstract

Rejection with severe hemodynamic compromise is a significant source of morbidity and mortality for pediatric heart transplant patients. Traditionally, treatment for these patients includes inotropes and escalation to extracorporeal membrane oxygenation (ECMO) when necessary. There is increasing interest in using percutaneous ventricular assistive devices in the pediatric population as a less invasive alternative to ECMO. We report the largest case series to date of biventricular support using percutaneous Impella devices. Retrospective case series was performed by chart review. Hemodynamics, left ventricular ejection fraction (LVEF), and indices of end organ function were collected before and after Impella placement. A 14‐year‐old male, 18‐year‐old male, and 19‐year‐old female, all status post heart transplant, presented with severely decreased biventricular function due to presumed clinical rejection, requiring maximal inotropic support without improvement. In all the three cases, simultaneous Impella CP and RP devices were placed percutaneously. Prior to implantation, LVEFs were 40%, 23%, and 25%, respectively. Hemodynamics measured invasively prior to device placement showed elevated filling pressures. Adverse events while on support included bleeding, hemolysis, and right femoral arterial dissection during implantation. All patients were successfully weaned from the devices and survived to discharge. The average time of right‐sided support and total support was 11 days and 13 days, respectively. After device removal, right‐sided pressures and echocardiographic measurements showed improvement in all patients. Bilateral Impella configuration (BiPella) is a viable option for temporary mechanical circulatory support in pediatric patients with significant graft dysfunction.

Clinical approach to mechanical circulatory support in the transplant patient from the Pediatric Heart Transplant Society

“…Temporary device options include the percutaneously implanted Impella LVAD (Abiomed, Inc.), and Impella RP RVAD 23–26 . The Impella remains a small but growing proportion of any study evaluating temporary devices in pediatrics 27,28 .…”

“…ECMO support should be continued until end-organ recovery is achieved and myocardial function has either recovered or unfavorably plateaued necessitating long-term mechanical support. Limited case reports exist describing the use of Impella devices for temporary LVAD or BiVAD support in the setting of acute rejection in pediatric patients, 23,24 but there has been no comparison of outcomes when using this device compared to ECMO support. Given this, in cases of acute rejection requiring mechanical support, ECMO should be considered as a first option for most patients.…”

“…Temporary device options include the percutaneously implanted Impella LVAD (Abiomed, Inc.), and Impella RP RVAD. [23][24][25][26] The Impella remains a small but growing proportion of any study evaluating temporary devices in pediatrics. 27,28 In contrast, the PediMag, CentriMag, and RotaFlow (Maquet) devices are more ubiquitous in the pediatric temporary support armamentarium.…”

Mechanical unloading by miniature axial flow pumps in late cardiac allograft failure due to acute rejection

“…Furthermore, biventricular Impella pump employments (Impella CP and RP, BiPella) were recently described in two case series of pediatric transplanted patients with a comparable profile of adverse events, including bleeding, hemolysis and femoral arterial dissection [ 9 , 10 ].…”

Clinical approach to acute cellular rejection from the pediatric heart transplant society

“…Response to treatment may take several days and temporary mechanical support may be necessary. 12,13 There are many dosing considerations for rATG:…”