Use of Transcarotid IMPELLA 2.5 Axial-Flow Pump Device for Left Ventricle Unloading During VA-ECMO Support in Pediatric Acute Heart Failure

What the pediatric nurse needs to know about the Impella cardiac assist device

Background: Cardiogenic shock in children still carries a high mortality risk despite advances in medical therapy. The use of temporary mechanical circulatory supports is an accepted strategy to bridge patients with acute heart failure to recovery, decision, transplantation or destination therapy. These devices are however limited in children and extracorporeal membrane oxygenation (ECMO) remains the most commonly used device. Veno-arterial ECMO may provide adequate oxygen delivery, but it does not significantly unload the left ventricle, and this may prevent recovery. To improve the likelihood of left ventricular recovery and minimize the invasiveness of mechanical support, the Impella axial pump has been increasingly used in children with acute heart failure in the last decade. Purpose: There are still limited data describing the Impella indications, management and outcomes in children, therefore, we aimed to provide a comprehensive narrative review useful for the pediatric nurses to be adequately trained and acquire specific competencies in Impella management.

Use of microaxial flow pumps in adolescents

Objectives

The Impella 5.5 has been successfully used in the adult population; however, safety and efficacy data in patients aged less than 18 years are limited.

Methods

Six pediatric patients, aged 13 to 16 years and weighing 45 to 113 kg, underwent axillary artery graft placement and attempted placement of the Impella 5.5 device at our institution between August 2020 and March 2023.

Results

Indications for implantation were heart failure secondary to myocarditis (2), rejection of prior orthotopic heart transplant, idiopathic dilated cardiomyopathy (2), and heart failure after transposition of the great arteries repair. Placement was unsuccessful in a 13.8-year-old female patient due to prohibitively acute angulation of the right subclavian artery, and venoarterial extracorporeal membrane oxygenation cannulation was performed via the axillary graft. In 5 patients with successful Impella 5.5 placement, median duration of support was 13.5 days (range, 7-42 days). One experienced cardiac arrest secondary to coagulation-associated device failure, requiring temporary HeartMate3 implantation. Four patients were bridged to transplant; 3 patients received a transplant directly from Impella 5.5, and 1 patient received a transplant after HeartMate3. The final patient received the HeartMate3 on Impella day 42 and is awaiting transplant.

Conclusions

Although exact size cutoffs and anatomy are still being determined, our experience provides a framework for use of the Impella 5.5 in adolescents.

Trans-subclavian approach for Impella CP implantation using the chimney graft in a pediatric patient with fulminant myocarditis during extracorporeal support

Impella is a device effective for the treatment of cardiogenic shock. However, among small children, its application has limitations due to left ventricle size and vasculature and the turning diameter of the aortic arch. Herein, we report an 11-year-old girl with fulminant myocarditis who was successfully managed with Impella CP implantation via the right subclavian artery using a polyethylene terephthalate chimney graft. Compared with insertion via the femoral artery, this method has several advantages. That is, it can address limitations in aortic arch diameter and facilitate equable fixation of the Impella device in small pediatric patients.