Epicardial echocardiography for correct placement of the intracardial biventricular assist device (Impella)

Implantation of Impella CP left ventricular assist device under the guidance of three-dimensional intracardiac echocardiography

Impella CP is a percutaneously inserted left ventricular assist device indicated for temporary mechanical cardiac support during high risk percutaneous coronary interventions and for cardiogenic shock. The potential application of Impella has become particularly relevant during the current COVID-19 pandemic, for patients with acute severe heart failure complicating viral illness. Standard implantation of the Impella CP is performed under fluoroscopic guidance. Positioning of the Impella CP can be confirmed with transthoracic or transoesophageal echocardiography. We describe an alternative approach to guide intracardiac implantation of the Impella CP using two-dimensional and three-dimensional intracardiac echocardiography. This new technique can be useful in selected groups of patients when fluoroscopy, transthoracic and transoesophageal echocardiography is deemed inapplicable or limited for epidemiological or clinical reasons. Intracardiac three-dimensional echocardiography is a feasible alternative to the traditional techniques for implantation of an Impella CP device but careful consideration must be given to the potential limitations and complications of this technique.

Cardiac failure: Mechanical support strategies

OBJECTIVE

Mechanical support of the circulation is necessary when heart failure becomes refractory to medical support and is typically applied when organ dysfunction occurs as a result of hypoperfusion. However, in timing the intervention, it is important to apply mechanical support before multiple organ failure occurs. The objective of this work is to review the current strategies for mechanical circulatory support in patients with refractory cardiac failure.

DESIGN

A review of the use of mechanical circulatory support is presented for patients with refractory cardiac failure.

PATIENTS

Data are taken from human studies that were selected to best exemplify the results that may be obtained from various forms of mechanical circulatory support.

INTERVENTIONS

Commonly applied forms of mechanical support include mechanical ventilatory support, intraaortic balloon counterpulsation, and hemodialysis or ultrafiltration. If these measures fail, mechanical support of the circulation with ventricular assist devices is possible in specialized centers with expertise in the implantation and management of these devices. The decision to pursue mechanical circulatory support in the critically ill patient is based on the cause of acute decompensation, the potential reversibility of the condition, and the possibility for other treatments to improve the underlying condition or, in highly selected cases, heart transplantation. Newer forms of ventricular assistance that require less surgery are becoming available and may allow use in a broader range of critically ill patients.

MAIN RESULTS

There is a range of means to mechanically support the circulation in patients with advanced heart failure.

CONCLUSIONS

A variety of means to support the circulation have found application in the treatment of patients with refractory heart failure. More work is required to best identify populations who will benefit from the therapy and to refine the therapy to reduce associated risks.

Echocardiographic approach in a new left ventricular assist device: impella recover 100

Echocardiographic evaluation represents a basic tool for the treatment of patients undergoing ventricular assist device implant. Impella Recover 100 is a new left intraventricular assist device proposed for short-term mechanical circulatory support to be implanted without cardiopulmonary bypass. We report our experience with echocardiographic monitoring on a patient with ischemic cardiomyopathy who underwent Impella Recover 100 implant as a bridge to heart transplant. During the surgical procedure echocardiography had an essential role for anatomic evaluation of the heart and correct intraventricular positioning of the device. Moreover, during the whole period of assistance, echocardiography contributed to assessment of patient-device interaction and to check the device when malfunction was suggested.

Initial experience with a new right ventricular support device for beating heart surgery

OBJECTIVE

Device supported beating heart surgery has been advocated to extend patient selection criteria for off-pump surgery. This article reports the initial experimental and clinical results with a novel paracardial right ventricular support device.

METHODS

Preclinical experiments were performed in two pigs. Ten elective patients with triple vessel disease were subjected to beating heart coronary artery bypass grafting surgery during right ventricular support by the paracardial device. Measurements included intraoperative hemodynamics during cardiac tilting, perioperative left ventricular ejection fraction (LVEF), hemolysis parameters, mortality and major morbidity events.

RESULTS

A mean of 3.2 +/- 0.2 distal anastomoses per patient were performed. Mean arterial pressure and central venous oxygen saturation remained stable during cardiac tilting. Perioperative LVEF did not vary significantly. Sixty-day mortality and postoperative infarction rate were 0%. Functional Canadian Cardiovascular Society class at 6 days after surgery was 1.2 +/- 0.1 vs. 3.3 +/- 0.2 pre-operatively.

CONCLUSION

In this initial clinical experience, application of the novel paracardial right ventricular support device proved to be safe and efficient.