Mechanical Unloading by Impella CP in Postinfarction Posterior Ventricular Septal Defect, Bridging to Repair: First Case Series

Objectives: Postinfarction ventricular septal defect (VSD) is a rare but serious event. Mortality approaches 50% with surgical repair and 100% in patients treated medically. Until now, the Stabilization was attempted with medical therapy, intraaortic balloon pump counterpulsation (IABP) and Extracorporeal machine oxygenators (ECMO). The aim of this study was to examine the safety and effectiveness of Impella-CP as a targeted circulatory support device for ventricular unloading as a bridge to surgical therapy in patients with postinfarction VSD.

Methods: In this retrospective analysis, all patients between May 2016 and June 2018 who were admitted to a single institution with posterior infarction VSD, were in cardiogenic shock and received the Impella CP temporary assist device system for stabilization were included in this study. The primary outcome was successful continuous support until surgery, and the secondary outcomes were device-related complications, the need of a second mechanical support, and days of successful support.

Result: Twelve patients met the inclusion criteria and were included in the study. The mean age was 67 ± 5 years. Eight patients were males, 8 were under chronic dialysis, and 11 patients were mechanically ventilated. The mean left ventricular ejection fraction was 37 ± 7%. The mean VSD size was 19 ± 3 mm. The mean pulmonary artery pressure was 43 ± 6 mm Hg, with a mean pulmonary wedge pressure of 34 ± 5 and a shunt fraction (Qp/Qs) of 2.7 ± 0.3. Successful PCI with stenting of the right coronary artery and subsequent insertion of Impella CP was performed in all patients. There were no device-related complications. Under Impella, the shunt fraction (Qp/Qs) dropped to 1.5 ± 5, the mean pulmonary pressure to 38 ± 4, and the pulmonary wedge pressure to 26 ± 4. Nine patients showed clinical and hemodynamic improvement under Impella-CP device with successful bridging to surgical repair. The mean time of successful support was 8 ± 2 days. Two patients primarily required additional ECMO support for respiratory failure, one of which died with multiorgan failure. Two further patients died with septic shock despite adequate circulatory support.

Conclusion: The preoperative use of Impella is a feasible option for patients with postinfarction basal/posterior VSD. It is effective in hemodynamic stabilization and it is suitable as a bridge to repair. Patients with posterior infarction VSD and respiratory failure may benefit from a combination of Impella ventricular unloading and ECMO support.

Publication History

Article published online:
19 February 2021