Successful Treatment of Heart Failure due to Acute Transplant Rejection With the Impella LP 5.0

Mechanical unloading by miniature axial flow pumps in late cardiac allograft failure due to acute rejection

Allograft failure secondary to rejection commonly requires a multimodal treatment, ultimately including mechanical circulatory support. A few case reports have demonstrated the use of Impella-devices due to its assumed favorable safety profile in this fragile cohort. However, this treatment option does not play a role in choice of anti-rejective therapy in clinical routine up to date. We summarize our institutional experiences and literature mini-review on Impella-based treatment strategies in allograft rejection after heart transplantation. In all seven cases, three from our institution and four reported in the literature, Impella-based therapies led to hemodynamic stabilization in allograft failure secondary to rejection. Adverse events included hemolysis, non-fatal bleeding and in one patient a relevant aortic valve insufficiency occurred. All patients showed an improvement of allograft function. Two patients died in context of severe immunosuppression or late secondary organ failure. Based on the limited available data, we propose that Impella-mediated mechanical unloading represents a valuable option for hemodynamic stabilization in severe allograft failure due to rejection, enabling an initiation of causal therapy and thereby potentially representing an opportunity to prevent mortality. Furthermore, we hypothesize it might add to the traditional therapeutic approaches by facilitating recovery by decompressing the myocardium in allograft rejection.

Perioperative Management of the Cardiac Transplant Recipient

Management of the cardiac transplant recipient includes careful titration of inotropes and vasopressors. Recipient pulmonary hypertension and ventilatory status must be optimized to prevent allograft right ventricular failure. Vasoplegia, coagulopathy, arrhythmias, and renal dysfunction also require careful management to achieve an optimal outcome. Primary graft dysfunction (PGD) can be an ominous problem after cardiac transplantation. Although mild degrees of PGD may be managed medically, mechanical circulatory support with extracorporeal membrane oxygenation or temporary ventricular assist devices may be required. Retransplantation may be necessary in some cases.

Surgical implant techniques of left ventricular assist devices: an overview of acute and durable devices

Left ventricular support for the failing heart has evolved to include short-term and long-term devices. These devices are implanted percutaneously and surgically. This manuscript provides a general overview of the contemporary, typically practiced, implant techniques with additional insight on minimally invasive approaches.

Percutaneous Assist Devices for Left Ventricular Shock

Percutaneous ventricular assist devices (PVADs) are increasingly being used for hemodynamic support in patients with cardiogenic shock as well as for patients undergoing high-risk cardiovascular procedures. The currently available PVADs for left ventricular shock are reviewed; the evidence for supporting PVAD use is discussed, and the authors' perspective on their unique clinical applications is offered.

Left ventricular venting through the right subclavian artery access during peripheral extracorporeal life support

The use of peripheral extracorporeal life support during refractory cardiac arrest sometimes exposes the patient to left ventricular dilatation requiring venting. We report here a simple technique for LV venting by a cannula inserted through right subclavian artery and positioned in the left ventricle.

Using the Impella 5.0 with a Right Axillary Artery Approach as Bridge to Long-Term Mechanical Circulatory Assistance

Purpose

Impella 5.0 is a short-term left ventricle assist device (LVAD), inserted retrograde into the left ventricle across the aortic valve through a surgical peripheral access. Impella has been utilized for various indications but in the setting of bridge-to-bridge application there are limited reports.

Methods

We performed a retrospective observational analysis of Impella utilization at our institution as bridge to long-term LVADs. The primary end-point was survival during Impella support.

Results

Between December 2010 and February 2012, we implanted 20 Impella in patients with cardiogenic shock and, among these, 5 were implanted as bridge to long-term LVADs. In this latter group, mean age at the time of implantation was 44 ∓ 15.6 (range 27-68) years and there was a prevalence of males (80%). Etiology of cardiogenic shock was: decompensated anthracycline-induced cardiomyopathy (n = 1), myocardial infarction (n = 4). There was no major bleeding requiring surgical revision or infectious complications at the right axillary access. One patient required Impella replacement due to a pump stop. After a mean period of 14.2 ∓ 9.0 (range 6-27) days of Impella support, patients were switched to a long-term LVAD (Jarvik 2000, n = 2; HeartMate II, n = 3). One patient died 70 days after implantation of the long-term LVAD due to multi-organ failure, while the remaining patients are still alive after a mean period of follow-up of 108.6 ∓ 66.2 (range 19-191) days.

Conclusions

Our experience shows that an Impella 5.0 implanted through the right axillary artery approach is a valid option as bridge to long-term LVADs.