Interprovincial spoke-to-hub transport using the Impella Recover LP 5.0 left ventricular assist device as a bridge to long-term circulatory support

Abstract

C urrent hospital administrative practices categorize health care centres in a network of spokes and hubs (1). The 'spokes' are primary care centres that offer immediate yet temporary life-sustaining therapies, and channel the most severe cases to centres or 'hubs' that can provide the long-term treatment not available at the spoke sites. In the setting of mechanical circulatory support, long-term left ventricular assist devices (LVADs) and transplant therapies are only used at a few hub centres. The relatively lower technical requirements of the Impella Recover LP 5.0 LVAD (ABIOMED Inc, USA) translate into greater utilization by spoke centres for the treatment of cardiogenic shock (2,3). Based on a literature review, we report the first case demonstrating successful use of the Impella Recover LP 5.0 LVAD, implanted under local anesthetic, for the purpose of interprovincial spoke-to-hub transport in a bridge-to-bridge-to-transplant procedure. case presentationMr S is a 54-year-old man with a greater than 10-year history of nonischemic dilated cardiomyopathy and symptomatic congestive heart failure managed medically. Following a sudden onset of angina, he presented to his local rural hospital and was diagnosed with an anterior ST elevation myocardial infarction complicated by high-grade atrioventricular block. Following stabilization with dopamine (5 µg/kg/min to 15 µg/kg/min) and insertion of a transvenous pacing wire, the patient was transferred to a tertiary care centre with cardiac surgery onsite, approximately 2 h away. On arrival, the patient had a blood pressure of 86/69 mmHg, a heart rate of approximately 70 beats/min (paced), a respiratory rate of 18 breaths/min and a hemoglobin saturation of 95% on 5 L supplemental oxygen. He had an increased jugular venous pressure of approximately 5 cm to 6 cm, with cool and clammy extremities. The electrocardiogram demonstrated third-degree atrioventricular block with increasing frequency of nonsustained ventricular tachycardia. He underwent emergent percutaneous coronary catheterizaton and thrombectomy of his proximal left anterior descending artery, with the remaining coronary arteries essentially unremarkable. The culprit lesion was not stented due to the patient's severe acetylsalicylic acid allergy and the potential need for heart transplantation. Despite restoration of Thrombolysis in Myocardial Infarction 3 flow following the procedure, the patient required increasing circulatory support, at which time an intra-aortic balloon pump (IABP) was inserted. The documented left ventricular end-diastolic pressure at this time was 39 mmHg. In the hours following, despite the use of inotropic Current hospital administrative practices categorize health care centres in a network of 'spokes' (primary care centres) and 'hubs' (tertiary care centres). For the treatment of cardiogenic shock, long-term left ventricular assist devices (LVADs) and transplant therapies are only used at a few hub centres nationwide and are, thus, only available to patients living in close proximit...

Mechanical assistance of the circulation during cardiogenic shock

“…Short-term VADs are also applied for interhospital transfer [19,70,71]. The first paediatric transatlantic transportation (8770 km) on a paracorporeal pulsatile LVAD was achieved without adverse haemodynamic events [72].…”

“…Small studies show encouraging results with ECMO or VAD support with the Centrimag Levitronix and the Impella Recover [12,18,23,28,32,39,50,53,55,56,67,71,83].…”

Mechanical Bridge to Decision: What Are the Options for the Management of Acute Refractory Cardiogenic Shock?

“…Aortic valve injury and device-induced aortic regurgitation are extremely rare. Recently, spoke-to-hub transport for a patient with the LP 5.0 system was reported [28]. The LP 5.0 system was implanted in five patients with post-myocardial infarction cardiogenic shock via a right axillary approach, thereby avoiding median sternotomy and complications related to femoral artery cannulation [29].…”

First Experience of Transfer with Impella 5.0 Over the Long Distance in Japan

“…1) Impella can be inserted percutaneously and directly unloads the left ventricle, and it has been reported as a useful temporary MCS for bridging to HTx or durable LVAD. 2,3) Successful experiences of transportation with Impella over long distance have already been reported in Canada or the US, 4,5) but never to date in Japan. Here, we present the first case of a patient who was safely transported with Impella 5.0 over 450 km in Japan.…”