1 Even in the presence of nearly complete cardiopulmonary bypass (CPB) during VA ECMO, some blood will return to the left ventricle (LV). Unlike traditional LV assist device (LVAD) support, VA ECMO pressurizes the systemic arterial circuit without directly unloading the left side of the heart. As a result, the failing LV might not have sufficient contractility to open the aortic valve. This causes progressive LV distention, which impairs myocardial recovery and can lead to pulmonary edema, pulmonary hemorrhage, or LV thrombus formation.2,3 Several approaches to LV decompression have been successfully used, including atrial septostomy, percutaneous placement of a pulmonary artery drainage catheter, intra-aortic balloon pumps (IABPs), percutaneous or direct placement of LV vents, and percutaneously placed microaxial pumps.
4,5The Impella ® 5.0 (Abiomed, Inc.; Danvers, Mass) is a percutaneous LVAD that is positioned across the aortic valve with inflow in the LV and outflow in the ascending aorta. This configuration augments forward flow and directly decompresses the LV. The Impella family of devices has been used for postcardiotomy circulatory support, cardiac support during high-risk percutaneous coronary intervention, treating cardiogenic shock after myocardial infarction, and treating viral myocarditis. 6 The devices have also been successfully used for LV decompression after percutaneous placement during peripheral VA ECMO. 7 We report our direct aortic placement of the Impella 5.0 in conjunction with centrally cannulated VA ECMO.
Case ReportIn July 2014, a 59-year-old man with a history of myocardial infarction, stroke, hypertension, and hyperlipidemia was seen for angina by his cardiologist. Myocardial infarction was ruled out, and results of cardiac catheterization revealed 3-vessel coronary artery disease. Echocardiograms showed an LV ejection fraction of 0.45 and no substantial valvular disease. At our hospital, the patient underwent 3-vessel offpump coronary artery bypass grafting. The target vessels were of poor quality, and the operation was complicated by graft occlusion that necessitated thrombectomy of venous grafts to the ramus intermedius and posterior descending coronary artery, and IABP placement. Flow in the left internal mammary artery graft to the left anterior descending coronary artery was low because of poor runoff. In the intensive care unit (ICU), the patient needed support with dobutamine, vasopressin, norepinephrine, and epinephrine.