Limits...
Impella LD microaxial pump supporting combined mitral and coronary surgery in a patient with dilated cardiomyopathy. A short bridge to recovery?

Szafron B, Smoczyński RH, Drobiński D, Pawlak A, Wojciechowski D, Liszka IM, Witkowska A, Kaliciński Z, Gil R, Suwalski P - Kardiochir Torakochirurgia Pol (2015)

Bottom Line: The case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the Impella LD pump is presented.Various options of applying the Impella device are discussed, especially as a bridge to transplant or bridge to recovery.Abstract available from the publisher.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiac Surgery, Central Teaching Hospital of the Ministry of Interior, Warsaw, Poland.

ABSTRACT
Cardiac surgeons have to face the problem of impaired left ventricle function in patients undergoing routine valve or coronary procedures. The intra-aortic balloon pump is not always effective in preventing cardiac failure. The idea of using a microaxial rotating pump as a short-term perioperative support seems to be a convenient solution. The case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the Impella LD pump is presented. Various options of applying the Impella device are discussed, especially as a bridge to transplant or bridge to recovery.

No MeSH data available.


Related in: MedlinePlus

Impella device in the ascending aorta, approaching the aortic valve
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4520509&req=5

Figure 0002: Impella device in the ascending aorta, approaching the aortic valve

Mentions: A 64-year-old woman suffering from ischemic dilated cardiomyopathy associated with mitral insufficiency was referred for combined treatment consisting of resynchronisation therapy followed by simultaneous coronary and mitral surgery. Initial echocardiography revealed impaired global contractility (ejection fraction [EF] 10-15%), dilated left ventricle (left ventricle end diastolic diameter [LVEDD] 7.8 cm), significant ventricular asynchrony (50 ms) and moderate mitral regurgitation (vena contracta [VC] 6 mm) due to both restriction of the posterior leaflet and dilation of the mitral annulus (5.5 cm). There were no significant abnormalities regarding the right ventricle, pulmonary valve and tricuspid valve. Clinically the patient presented with end stage cardiac failure including resting dyspnea (NYHA IV). The patient underwent uneventful implantation of an ICD CRD (Maximo II), which resulted in improved exercise tolerance. This was consistent with post-procedure echocardiography showing no significant ventricular asynchrony (4 ms), slightly improved contractility (EF 20%) and unchanged moderate mitral regurgitation (VC 6 mm). Therefore the patient was referred for combined cardiac surgery including mitral repair and coronary grafting. Because of poor LV function and the complexity of the procedure, it was decided to apply short-term mechanical support during and after surgery. The Impella LD microaxial pump was chosen due to the simplicity of implantation and the low anticoagulation regime. Also, the Impella LD does not require a hybrid theater with fluoroscopic guidance. Routine surgery was performed. The surgical approach was achieved via median sternotomy. Cardiopulmonary bypass was established by means of selective bicaval cannulation. Antegrade cold blood cardioplegic solution was administered through the aortic root. The posterior descending artery (PDA) and left anterior descending artery (LAD) were grafted with the long saphenous vein and left internal thoracic artery respectively. The left atrium was entered in a routine manner after dissecting Sondergaard's plane. On inspection the echocardiographic findings were confirmed. The valve was repaired with a Physio 26 mm ring. The only surgical issue was severe atherosclerosis of the ascending aorta affecting both anastomosis of the vein graft and implantation of the Impella device. Before the implantation the device was prepared as per protocol. The purge system with 20% dextrose was installed. The device was primed, deaired and checked. Before insertion a 10 mm Dacron graft was anastomosed to the ascending aorta using a side biting clamp (Fig. 1). The Impella catheter was inserted through the graft and then, under transesophageal echocardiographic (TEE) guidance, was forwarded through the ascending aorta and the aortic valve into the left ventricle (Figs. 2 and 3). Immediately after confirming the position the impeller rotation was initialized. The target flow was achieved gradually within a few minutes. Weaning from cardiopulmonary bypass was accomplished on minimal inotropic support. The echo scan showed significant offloading of the left ventricle (Fig. 4). Meticulous attention was paid to maintain proper left ventricle volume preloading in order to avoid pump malfunction. After securing hemostasis the chest was closed, letting the driveline out above the suprasternal notch and through the upper end of the sternotomy wound. The patient was transferred to intensive treatment unit (ITU) in a stable condition. There she was kept sedated and ventilated electively. Therapeutic activated clotting time (ACT) (160 s) was achieved by continuous heparin infusion. The position of the pump was checked daily and in case of any suspicion of malfunction. Adequate flow was maintained most of the time, with one episode of stopping of the machine, which was easily managed with fluid infusion. The inotropic support was reduced gradually without affecting hemodynamic stability. On the 2nd postoperative day the device was explanted electively in the operating theatre. The further postoperative course was mainly uneventful, although prolonged mechanical ventilation was required (8 days). Episodes of AF were managed pharmacologically. Consecutive echo scans confirmed mild mitral regurgitation and poor LV function as before surgery. The patient was discharged home 20 days after surgery without signs of cardiac failure. The first follow-up visit two months after discharge confirmed good exercise tolerance and satisfactory echocardiographic findings (trace mitral regurgitation, LVEDD 7.6 cm, EF 25%). Further regular outpatient follow-up has been arranged.


Impella LD microaxial pump supporting combined mitral and coronary surgery in a patient with dilated cardiomyopathy. A short bridge to recovery?

Szafron B, Smoczyński RH, Drobiński D, Pawlak A, Wojciechowski D, Liszka IM, Witkowska A, Kaliciński Z, Gil R, Suwalski P - Kardiochir Torakochirurgia Pol (2015)

Impella device in the ascending aorta, approaching the aortic valve
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4520509&req=5

Figure 0002: Impella device in the ascending aorta, approaching the aortic valve
Mentions: A 64-year-old woman suffering from ischemic dilated cardiomyopathy associated with mitral insufficiency was referred for combined treatment consisting of resynchronisation therapy followed by simultaneous coronary and mitral surgery. Initial echocardiography revealed impaired global contractility (ejection fraction [EF] 10-15%), dilated left ventricle (left ventricle end diastolic diameter [LVEDD] 7.8 cm), significant ventricular asynchrony (50 ms) and moderate mitral regurgitation (vena contracta [VC] 6 mm) due to both restriction of the posterior leaflet and dilation of the mitral annulus (5.5 cm). There were no significant abnormalities regarding the right ventricle, pulmonary valve and tricuspid valve. Clinically the patient presented with end stage cardiac failure including resting dyspnea (NYHA IV). The patient underwent uneventful implantation of an ICD CRD (Maximo II), which resulted in improved exercise tolerance. This was consistent with post-procedure echocardiography showing no significant ventricular asynchrony (4 ms), slightly improved contractility (EF 20%) and unchanged moderate mitral regurgitation (VC 6 mm). Therefore the patient was referred for combined cardiac surgery including mitral repair and coronary grafting. Because of poor LV function and the complexity of the procedure, it was decided to apply short-term mechanical support during and after surgery. The Impella LD microaxial pump was chosen due to the simplicity of implantation and the low anticoagulation regime. Also, the Impella LD does not require a hybrid theater with fluoroscopic guidance. Routine surgery was performed. The surgical approach was achieved via median sternotomy. Cardiopulmonary bypass was established by means of selective bicaval cannulation. Antegrade cold blood cardioplegic solution was administered through the aortic root. The posterior descending artery (PDA) and left anterior descending artery (LAD) were grafted with the long saphenous vein and left internal thoracic artery respectively. The left atrium was entered in a routine manner after dissecting Sondergaard's plane. On inspection the echocardiographic findings were confirmed. The valve was repaired with a Physio 26 mm ring. The only surgical issue was severe atherosclerosis of the ascending aorta affecting both anastomosis of the vein graft and implantation of the Impella device. Before the implantation the device was prepared as per protocol. The purge system with 20% dextrose was installed. The device was primed, deaired and checked. Before insertion a 10 mm Dacron graft was anastomosed to the ascending aorta using a side biting clamp (Fig. 1). The Impella catheter was inserted through the graft and then, under transesophageal echocardiographic (TEE) guidance, was forwarded through the ascending aorta and the aortic valve into the left ventricle (Figs. 2 and 3). Immediately after confirming the position the impeller rotation was initialized. The target flow was achieved gradually within a few minutes. Weaning from cardiopulmonary bypass was accomplished on minimal inotropic support. The echo scan showed significant offloading of the left ventricle (Fig. 4). Meticulous attention was paid to maintain proper left ventricle volume preloading in order to avoid pump malfunction. After securing hemostasis the chest was closed, letting the driveline out above the suprasternal notch and through the upper end of the sternotomy wound. The patient was transferred to intensive treatment unit (ITU) in a stable condition. There she was kept sedated and ventilated electively. Therapeutic activated clotting time (ACT) (160 s) was achieved by continuous heparin infusion. The position of the pump was checked daily and in case of any suspicion of malfunction. Adequate flow was maintained most of the time, with one episode of stopping of the machine, which was easily managed with fluid infusion. The inotropic support was reduced gradually without affecting hemodynamic stability. On the 2nd postoperative day the device was explanted electively in the operating theatre. The further postoperative course was mainly uneventful, although prolonged mechanical ventilation was required (8 days). Episodes of AF were managed pharmacologically. Consecutive echo scans confirmed mild mitral regurgitation and poor LV function as before surgery. The patient was discharged home 20 days after surgery without signs of cardiac failure. The first follow-up visit two months after discharge confirmed good exercise tolerance and satisfactory echocardiographic findings (trace mitral regurgitation, LVEDD 7.6 cm, EF 25%). Further regular outpatient follow-up has been arranged.

Bottom Line: The case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the Impella LD pump is presented.Various options of applying the Impella device are discussed, especially as a bridge to transplant or bridge to recovery.Abstract available from the publisher.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiac Surgery, Central Teaching Hospital of the Ministry of Interior, Warsaw, Poland.

ABSTRACT
Cardiac surgeons have to face the problem of impaired left ventricle function in patients undergoing routine valve or coronary procedures. The intra-aortic balloon pump is not always effective in preventing cardiac failure. The idea of using a microaxial rotating pump as a short-term perioperative support seems to be a convenient solution. The case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the Impella LD pump is presented. Various options of applying the Impella device are discussed, especially as a bridge to transplant or bridge to recovery.

No MeSH data available.


Related in: MedlinePlus