Percutaneous Impella LD Explantation

A 58-year-old man with a history of aortic valve repair “aortic valvotomy” at the age of 12 presented with dyspnoea, orthopnoea (NYHA IV), and bilateral lower limb oedema.

• His pro BNP was 4287ng/l.
• TTE und TEE showed low EF 20%, severe AS, AVA 0,5 cm2, DG 77/47, AI II, LVEDD 65 mm, LVESD 55 mm, LA 45 mm, severe LVH, and diastolic dysfunction with normal RV function.
• Coronary angiogram showed no coronary artery stenosis.
• Right and left heart catheter showed COP 3,8l/m, CI 1,81l/min/m2,PCWP 30 mmHg, PVR 355 (dynes ∗sec)/cm5 (most likely post-capillary pulmonary hypertension PAsys/PAM 72/47 mmHg), AVA 0,46cm2 (Gorlin), invasive aortic gradient 83/53 mm Hg, and LVEDP 38 mm Hg.
• Preoperative CT angiography showed severely calcific tricuspid aortic valve, aortic annulus of 27 mm, aortic ectasia of 43 mm, no aortic coarctation, and normal femoral vessels bilaterally.

One day later, the patient developed ventricular tachycardia (VT) which was terminated with DC 200 J. After that, a recurrent non-sustained VT was recorded (arrhythmogenic heart). An interdisciplinary valvular heart team recommended a high-risk redo aortic valve surgery followed by CRT-D implantation.

Because of severe adhesions between the right ventricle and inner table of the sternum, the surgical approach was performed via upper partial ministernotomy. CPB was established using femoro-femoral cannulation. Cold cardioplegia, Custodiol® crystalline cardioplgic solution was delivered antegradely. LV venting was through RSPV. AVR was performed in the usual manner using a 27 mm Edwards Perimount aortic valve prosthesis.

Taking into consideration the low EF 20%, elevated LVEDP 38 mm Hg, arrhythmogenic heart, severely dilated and distended LV confirmed by TOE despite initiation of CPB, the surgical team decided to insert the transaortic Impella LD under DIRECT VISION (The Early, The Better-Concept).

Surgical Technique
End-to-side anastomosis was performed using a 10 mm FlowWeave BIOSEAL textile vascular graft. Insertion of Impella LD (Abiomed Europe GmbH) was performed under DIRECT VISION through the aortic valve prosthesis. Fixation of the Impella was done with the graft. Closure of the aortotomy was done. Tunneling of the Impella LD through suprasternal notch was performed. The Impella inlet should be 3.5 cm below the aortic valve, guided by transesophageal echo (TEE).

The patient was weaned off CPB with minimal inotropic support. Aortic cross clamp time was 80 minutes, and CPB time was 102 minutes. Four hours after surgery, the patient was extubated (Lactate I,3 mmol/l, SvO2 68% and other arterial blood gases parameters were within normal ranges). CI was 3,2-3,8 l/min/m2 .

Early mobilization and recovery of the patient were enhanced through the Impella LD. On the third postoperative day, the Impella was weaned and removed percutaneously without opening the chest (TEE guided) with maintained hemodynamic parameters. The aortic valve remained intact without visible damage at all points. On the fifth postoperative day, the patient was transferred to the normal surgical ward. On the eighth postoperative day, the patient was discharged home in very good clinical shape.

Learning Points:

1. As with other VAD technologies, the patient’s pre-implant conditions have a determinant role on outcomes while using the Impella LD. Status of hemodynamics as well as residual cardiac function and end-organ function at the time of implant impacts patient outcomes (The Early, The Better- Concept).
2. The Impella LD actively unloads the LV, causes rapid restoration of normal end-organ perfusion (up to 5 L/min), and increases the coronary perfusion, thereby improving the myocardium oxygen supply/demand ratio.
3. Compared to other surgical short-term LVADs, the less-invasive implantation, ease of use, lower cost, and favorable safety profile offered by this technology make it very compelling and might fill a technological gap for perioperative patients who require early and potent circulatory support to restore normal cardiac function or to bridge them to next therapy.
4. It is well established in the literature that the overall mortality in patients with post-cardiotomy cardiogenic shock is frustratingly high when it is treated with increased inotropic and IABP support (mechanical placebo). Moreover, the improvement of hemodynamic parameters and COP is at the expense of increased myocyte death and derangement in the functionality of remaining myocytes.

References

1. Griffith BP, Anderson MB, Samuels LE, Pae Jr WE, Naka Y, Frazier OH. The RECOVER I: a multicenter prospective study of Impella 5.0/LD for postcardiotomy circulatory support. J Thorac Cardiovasc Surg. 2013 Feb;145(2):548-554,
2. Hanke JS, Dogan G, Haverich A, Schmitto JD. First-in-man explantation of a HeartMate 3 left ventricular assist device via customized plug. Eur J Cardiothorac Surg. 2020 Mar 1;57(3):604-606.

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