J Thorac Cardiovasc Surg 2006;132:989-990
© 2006 The American Association for Thoracic Surgery
Placement of the Impella Recover LD microaxial blood pump through a bioprosthesis is technically feasible
Andrea Garatti, MD,
Tiziano Colombo, MD,
Ettore Vitali, MD
"A. De Gasperis" Cardiac surgery Division, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, Milan 20162, Italy
(Email: agaratti{at}tiscali.it).
To the Editor:
We read with great interest the article of Strauch and colleagues1
regarding their experience with Impella Recover LD support for postcardiotomy low-output syndrome in a patient undergoing aortic valve replacement with a bioprosthesis. In our initial experience2 we reported the use of the Impella Recover LD to support a patient with valvular cardiomyopathy who underwent conventional mitral valve repair and aortic valve replacement with a 21 mm Carpentier-Edwards bioprosthesis. Despite maximal inotropic support (epinephrine dose, 0.2 µg/kg–1/min–1), the patient could not be weaned from extracorporeal circulation, with hypotension, increased filling pressure (left atrial pressure, 28 mm Hg), and oliguria (urine output, <30 mL/h). The calculated intra-aortic balloon pump (IABP) score for the patient was 2, which predicts a 52% 30-day mortality according to Hausmann and coworkers.3 The Impella LD was then implanted with the standard technique and advanced in the left ventricle through the prosthesis under echocardiographic guidance. In our experience passing the biologic valve was not immediate but requires some attempts. Transesophageal echocardiography confirmed right pump placement and no interference between valve leaflet movements and outflow-tip antegrade flow. A trivial aortic regurgitation was detected, probably because of the relative stiffness of prosthetic compared with natural valve leaflets. The postoperative course was characterized by persistent oliguria that required central veno–venous haemofiltration, with slow improvement of cardiac function. Inotropic support was continued for 6 days and then slowly decreased. After 15 days of support, the patient was weaned from the device and discharged home. Follow-up echocardiography showed markedly improved left ventricular contractility and good performance of the aortic valve without signs of damage to the leaflets.4
We agree with the author that in the setting of postcardiotomy heart failure, deciding when to start a patient on mechanical support without wasting any precious time is the key to success. Recently, we have introduced in our clinical practice the IABP score as a very useful tool in the decision-making process of mechanical support in postcardiotomy heart failure. Hausmann and colleagues3 defined an IABP score based on 4 parameters they found statistically significant to predict survival or death 1 hour after IABP implantation in patients with low-output syndrome in cardiac surgery. The Hausmann IABP score has been validated also by Siegenthaler and associates5 in their study of 24 patients supported with the Impella LD for postcardiotomy heart failure. In addition, they were able to identify patients who will not benefit from the Impella Recover. Patients with a residual cardiac function of 1 L/min or less had an 88% chance of death. This observation is likely due to the fact that the Impella device provides insufficient support in the presence of virtually absent myocardial function.
In conclusion, we agree with the authors that timely insertion of such a device in the postcardiotomy setting, even in borderline situations or after stented biologic aortic valve prosthesis implantation, can provide a greater chance of survival in a poor-prognosis population. Careful clinical, hemodynamic, and residual cardiac function evaluation can allow surgeons to stratify patients for prolonged IABP-inotropic support or timely Impella implantation or even to receive a conventional left ventricular assist device if cardiac performance is dismal.
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References
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- Strauch JT, Franke UFW, Breuer M, et al. Technical feasibility of Impella Recover 100 microaxial left ventricular assist device placement after biological aortic valve replacement (21 mm) for postcardiotomy failure. J Thorac Cardiovasc Surg 2005;130:1715-1716.[Free Full Text]
- Garatti A, Colombo T, Russo C, et al. Impella Recover 100 microaxial left ventricular assist device: the Niguarda experience. Transplant Proc 2004;36:623-626.[Medline]
- Hausmann H, Potapov EV, Koster A, et al. Prognosis after the implantation of an Intra-Aortic Balloon Pump in Cardiac Surgery calculated with a new score. Circulation 2002;106(suppl I):I203-I206.[Medline]
- Garatti A, Colombo T, Russo C, et al. Different applications for left ventricular mechanical support with the Impella Recover 100 microaxial blood pump. J Heart Lung Transplant 2005;24:481-485.[Medline]
- Siegenthaler MP, Brehm K, Strecker T, et al. The Impella Recover microaxial left ventricular assist device reduces mortality for postcardiotomy failure: a three-center experience. J Thorac Cardiovasc Surg. 2004;127:812-822.[Abstract/Free Full Text]
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References