Impella 5.5 Support for Delayed Surgical Ventricular Septal Defect Repair—A Paradigm Shift?

Abstract

Background Ventricular septal defects (VSDs) remain a rare but life-threatening complication of myocardial infarction. Although the incidence has decreased due to better treatment options, the mortality rate remains high. The timing of VSD repair remains critical to outcome. The use of mechanical circulatory support is rarely described in the literature, although it may help to delay repair to allow tissue stabilization. While Impella is currently considered contraindicated due to the potential worsening of the right-to-left shunt and possible systemic embolization of necrotic debris, there is no comprehensive evidence for this. Therefore, we aimed to analyze whether the use of Impella 5.5 as a first choice for patients undergoing VSD repair should be considered for discussion.

Methods This retrospective study analyses four consecutive patients who underwent delayed ventricular septal repair after prior implantation of Impella 5.5 (Abiomed Inc., Danvers, Massachusetts, United States).

Results A total of 75% of patients (n = 3) presented with acute right heart failure prior to implantation with a mean systolic pulmonary artery pressure of 64 ± 3.0 mmHg. Implantation was performed under local anesthesia in three cases. The mean time to surgery was 9.8 ± 3.1 days. All patients remained on the Impella 5.5 device postoperatively. Weaning from Impella 5.5 was successful in 75% (n = 3). The mean length of stay in the intensive care unit was 22.3 ± 7.5 days.

Conclusion Preoperative implantation of the Impella 5.5 device is a safe and feasible option for patients undergoing VSD repair. Outcomes may be improved by performing Impella implantation under local anesthesia and continuing Impella support after VSD repair. However, it is important to note that these patients represent a high-risk cohort and the mortality rate remains high.

Keywords

circulatory support - ventricular septal defect - myocardial infarction - outcomes - surgery

• References

• 1 López-Sendón J, Gurfinkel EP, Lopez de Sa E. et al; Global Registry of Acute Coronary Events (GRACE) Investigators. Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events. Eur Heart J 2010; 31 (12) 1449-1456
• 2 Singh V, Rodriguez AP, Bhatt P. et al. Ventricular septal defect complicating ST-elevation myocardial infarctions: a call for action. Am J Med 2017; 130 (07) 863.e1-863.e12
• 3 Gong FF, Vaitenas I, Malaisrie SC, Maganti K. Mechanical complications of acute myocardial infarction: a review. JAMA Cardiol 2021; 6 (03) 341-349
• 4 Moreyra AE, Huang MS, Wilson AC, Deng Y, Cosgrove NM, Kostis JB. MIDAS Study Group (MIDAS 13). Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol 2010; 106 (08) 1095-1100
• 5 Crenshaw BS, Granger CB, Birnbaum Y. et al; GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000; 101 (01) 27-32
• 6 Jeppsson A, Liden H, Johnsson P, Hartford M, Rådegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Eur J Cardiothorac Surg 2005; 27 (02) 216-221
• 7 Deja MA, Szostek J, Widenka K. et al. Post infarction ventricular septal defect - can we do better?. Eur J Cardiothorac Surg 2000; 18 (02) 194-201
• 8 Ronco D, Matteucci M, Kowalewski M. et al. Surgical treatment of postinfarction ventricular septal rupture. JAMA Netw Open 2021; 4 (10) e2128309
• 9 Pahuja M, Schrage B, Westermann D, Basir MB, Garan AR, Burkhoff D. Hemodynamic effects of mechanical circulatory support devices in ventricular septal defect. Circ Heart Fail 2019; 12 (07) e005981
• 10 McLaughlin A, McGiffin D, Winearls J. et al. Veno-arterial ECMO in the setting of post-infarct ventricular septal defect: a bridge to surgical repair. Heart Lung Circ 2016; 25 (11) 1063-1066
• 11 Ruiz Duque E, Hohenwarter MR, Isom NR, Singhal AK. Impella support for surgical ventricular septal defect repair. ASAIO J 2023; 69 (06) e278-e283
• 12 Jiménez-Rodríguez GM, Rojas-Velasco G, Arias-Sánchez EA. et al. Left atrial veno-arterial extracorporeal membrane oxygenation in post-myocardial infarction ventricular septal defect with cardiogenic shock: a case report. Eur Heart J Case Rep 2023; 7 (08) ytad393
• 13 Ruhparwar A, Zubarevich A, Osswald A. et al. ECPELLA 2.0-Minimally invasive biventricular groin-free full mechanical circulatory support with Impella 5.0/5.5 pump and ProtekDuo cannula as a bridge-to-bridge concept: a first-in-man method description. J Card Surg 2020; 35 (01) 195-199
• 14 Jones BM, Kapadia SR, Smedira NG. et al. Ventricular septal rupture complicating acute myocardial infarction: a contemporary review. Eur Heart J 2014; 35 (31) 2060-2068
• 15 Eghbalzadeh K, Wahlers TCW, Deppe AC. Implanting Impella 5.5 under local anesthesia. Thorac Cardiovasc Surg 2023; 72 (04) 296-299
• 16 Jalli S, Spinelli KJ, Kirker EB, Venkataraman A, Abraham J. Impella as a bridge-to-closure in post-infarction ventricular septal defect: a case series. Eur Heart J Case Rep 2023; 7 (10) ytad500
• 17 Maeda K, Yoshioka I, Saiki Y. Emergence of right to left shunt via postmyocardial infarction ventricular septal defect under Impella support. Artif Organs 2021; 45 (03) 316-317