Escalation from Impella 5.5 to ECPELLA Support as a Bridge to Mitral Valve Surgery in a Patient with Degenerative Mitral Regurgitation
Author Type(s)
Faculty, Student, Resident/Fellow
Document Type
Abstract
Publication Date
4-2023
DOI
10.1177/02676591231186725
Journal Title
Journal of Heart and Lung Transplantation
Department
Surgery
Second Department
Medicine
Abstract
Introduction
Impella device is widely used to treat acute cardiogenic shock which can be combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO), known as “ECPELLA”. While functional mitral regurgitation (MR) in the setting of cardiogenic shock usually improves with unloading of the left ventricle (LV), the same may not occur in other forms of MR. Herein, we present a case of non-ischemic cardiomyopathy (NICM) with degenerative severe MR which required escalation from Impella 5.5 support to ECPELLA as a bridge to MV surgery.Case Report
A 57-year-old woman with a history of NICM presented with cardiogenic shock with severe MR. An intra-aortic balloon pump was placed and she was transferred to our center on inotropic support. Due to ongoing shock (mix venous saturation 49%, cardiac index [CI], 1.9 L/min/m2) with severe MR (pulmonary artery pressure [PAP], 78/32 mmHg, central venous pressure [CVP] 13 mmHg), axillary Impella 5.5 was placed. Intraoperative transesophageal echocardiography showed perforation of the anterior leaflet with severe MR. LV ejection fraction was 25%. Impella 5.5 was set at P9, which flowed 5.1 L/min with CI of 2.3-2.5 L/min/m2. Despite this, filling pressures did not change (PA, 72/32 mmHg, and CVP 12 mmHg) and the patient developed acute renal failure without evidence of hemolysis. Support was escalated via the addition of femoral VA-ECMO (ECMO flow, 2.7 L/min and Impella flow, 2.0 L/min at P5). After ECPELLA placement, PAP and CVP significantly improved to 21/13 mmHg and 7 mmHg, respectively, with recovery of renal function. Due to significant social contraindications to advanced therapies, such as left ventricular assist device or transplant, high risk MV surgery with ECPELLA support was performed. Following a successful MV replacement, VA-ECMO was weaned at the same time with maintenance of Impella 5.5. The Impella was removed 12 days post-operation and the patient was discharged off inotropic support.Summary
This case suggests that Impella alone may not be adequate in the setting of some severe degenerative MR cases with cardiogenic shock. Furthermore, when hemodynamic and/or clinical improvements are not observed after Impella placement in settings of degenerative MR, even with adequate Impella flow, escalation to further support such as ECPELLA may be considered.Recommended Citation
Gregory, V., Grunfeld, M., Kanwal, A., Bali, A. D., Pan, S., Spielvogel, D., Kai, M., & Ohira, S. (2023). Escalation from Impella 5.5 to ECPELLA Support as a Bridge to Mitral Valve Surgery in a Patient with Degenerative Mitral Regurgitation. Journal of Heart and Lung Transplantation, 42 (4 Suppl.), S411. https://doi.org/10.1177/02676591231186725
