Successful Use of Surgically Placed Impella 5.0 and Central Extracorporeal Membrane Oxygenation Circuit in a Patient with Postcardiotomy Shock

Abstract

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.

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation

“…Other complications of septostomy include needle perforation of the LA and/or pulmonary vein, pericardial effusion, cardiac tamponade, and ventricular fibrillation (32). Furthermore, atrial septostomy may not prevent LV stasis or thrombosis, and may require subsequent repair (6,46). Alkhouli et al [2016] found that the majority (50-75%) of iatrogenic ASDs spontaneously close by 6 to 12 months following simple septostomy (14).…”

“…It is available in three sizes that provide flows of up to 2.5, 3.5 or 5 L/min (53). Several adult and pediatric studies have shown that the use of an Impella device during VA-ECMO improves LVEDD, clinical and radiographic signs of pulmonary edema, and reduces PCWP and PVR (6,7,9,13,46,(54)(55)(56)(57). There is limited evidence that this combination improves survival compared with VA-ECMO alone (56).…”

The Transaxillary Approach via Prosthetic Conduit for Transcatheter Aortic Valve Replacement With the New-Generation Balloon-Expandable Valves in Patients With Severe Peripheral Artery Disease

“…This access facilitates the introduction of large self-expanding sheaths into the axillary artery and simplifies the valve mounting maneuver of the balloon-expandable system in the ascending aorta. The chimney approach overcomes access site complications and bleedings from overstretched self-expandable sheaths and is often used for central implanted mechanical circulatory support systems in the case of PAD ( 17 , 18 ).…”

Commentary: The time for last-resort measures—be prepared

“…Various ventricular unloading techniques have been proposed in this etiology of cardiogenic shock, such as decompression cannula directly inserted through the left ventricular apex, venting via the pulmonary vein or the left atrial appendage, or ventricular decompression with the Impella system (Abiomed, Danvers, Mass) with a surgical transaortic approach or percutaneously with femoral or subclavian artery access. 3 One may consider avoiding the additional surgical trauma to a struggling left ventricle (ie, manipulation associated with positioning the decompressing cannula through the ventricular apex), which could have a certain hypothetical benefit. Moreover, in patients with atrioventricular groove rupture, ventricular access via the mitral prosthesis is not recommended and handling of the friable cardiac mass and the fresh surgical repair could result in persistent massive bleeding.…”