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Impella-Supported Cardiac Surgery

Paolo Masiello, Generoso Mastrogiovanni, Mario Colombino, Francesco Cafarelli, Francesco Frunzo, Marco Padula, Donato Triggiani, Gerardo Del Negro, Emanuele Fiore, Severino Iesu

Background: Impella left ventricular assist devices are useful tools for the treatment of cardiogenic shock. The peri-operative use of Impella in patients with low left ventricular ejection fraction (LVEF) undergoing cardiac surgery, can be valuable for cardiac surgeons to prevent postcardiotomy cardiogenic shock.

Methods: From September 2018 to June 2019, 10 patients underwent cardiac surgery supported by Impella 5.0. Five patients underwent off-pump coronary artery bypass (OPCAB), two had OPCAB and mitral valve repair (MVR), and one each had aortic valve repair (AVR) plus MVR, OPCAB plus AVR, and left ventricular aneurysmectomy plus MV replacement. The Impella 5.0 was inserted surgically one day before the operative procedure via a side conduit through the left femoral artery in 8 cases and right axillary artery in 2 cases. The mean age of patients was 63 ± 7 years. Mean LVEF at baseline was 27.5% (20-32%) and mean duration of Impella support was 7 days (4-12 days).

Results: Hemodynamics improved immediately after the initiation of mechanical support. The cardiac surgical procedures were conducted in the usual manner. All patients received low dose of postoperative inotropes. Cardiac-related mortality was 10% (1/10), due to multiorgan failure (MOF) in 1 patient who underwent OPCAB. Major intracranial bleeding occurred in 2 patients who received extracorporeal circulation (ECC). Impella support was weaned in all patients after hemodynamics was optimized without inotropes, except the patient with MOF. The survivors had no major complications and were discharged to medical therapy at mean of 21 days.

Conclusion: Impella support is feasible for preconditioning before surgery and in the postoperative period. It enables cardiac surgery in patients with low EF using a low dose of inotropes and helps to prevent postcardiotomy cardiogenic shock. Impella support during OPCAB allows for easier positioning and unloading the heart. The underlying cause for intracranial bleeding in two cases despite successful weaning from Impella support remains to be understood.