The postoperative use of Impella as a ventricular assist device in high‐risk patients undergoing coronary artery bypass surgery: A case series and comparison

Preoperative intra-aortic balloon pump in patients with ST-elevation myocardial infarction undergoing urgent cardiac bypass surgery

BACKGROUND

In patients with ST-elevation myocardial infarction (STEMI), either with or without cardiogenic shock, mechanical circulatory support with an intra-aortic balloon pump (IABP) is not associated with lower mortality. However, in STEMI patients undergoing urgent coronary artery bypass grafting (CABG), preoperative insertion of an IABP has been suggested to reduce mortality. In this study, the effect of preoperative IABP use on mortality in STEMI patients undergoing urgent CABG was investigated.

METHODS

All consecutive STEMI patients undergoing urgent CABG in a single centre between 2000 and 2018 were studied. The primary outcome, 30-day mortality, was compared between patients with and without a preoperative IABP. Subgroup analysis and multivariable analysis using a propensity score and inverse probability treatment weighting were performed to adjust for potential confounders.

RESULTS

A total of 246 patients were included, of whom 171 (69.5%) received a preoperative IABP (pIABP group) and 75 (30.5%) did not (non-pIABP group). In the pIABP group, more patients suffered from cardiogenic shock, persistent ischaemia and reduced left ventricular function. Unadjusted 30-day mortality was comparable between the pIABP and the non-pIABP group (13.3% vs 12.3%, p = 0.82). However, after correction for confounders and inverse probability treatment weighting preoperative IABP was associated with reduced 30-day mortality (relative risk 0.52, 95% confidence interval 0.30-0.88).

CONCLUSION

In patients with STEMI undergoing urgent CABG, preoperative insertion of an IABP is associated with reduced mortality.

Management of Impella device fracture during direct aortic explantation

The utilisation of mechanical circulatory support devices in patients undergoing high-risk coronary artery bypass continues to increase. The Impella is a ventricular assist device commonly used in the setting of post-cardiotomy cardiogenic shock. This device can be implanted directly into the ascending aorta during open cardiac surgery. Device fracture is a documented complication of the Impella; however, the management of device fracture during direct explantation from an aortic graft has not yet been described. We report a case of Impella device fracture during its removal from a prosthetic aortic graft and discuss the management of this complication.

Impella insertion for residual aortic dissection

Acute aortic dissection with coronary malperfusion is a life-threatening disease, resulting in demanding postoperative management. We report a successful insertion of percutaneous heart pump Impella through the intact true lumen in a patient with residual aortic dissection after the graft replacement. Careful evaluation of the access site and the Impella size selection is required.

Valvular complications following the Impella device implantation

BACKGROUND

Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device.

METHODS

To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic.

RESULTS AND CONCLUSION

Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.