Advantages of intraoperative implantation of Impella 5.5 SmartAssist in the Management of Acute Post-Infarction Ventricular Septal Defect with cardiogenic shock

Jeko M Madjarov,Michael G Katz,Shahood Fazal,Svetozar Madzharov,Francis Robicsek

doi:10.1186/s13019-021-01513-y

Abstract

BackgroundDespite advances in surgical techniques and aggressive therapy of post-infarction ventricular septal defect (VSD) with cardiogenic shock, the overall morbidity and mortality is frustratingly high. The Impella 5.5 SmartAssist (Abiomed, Danvers, MA) is a surgically implanted temporary device, recently approved by the FDA (https://www.businesswire.com/news/home/20190925005454/en/) for treatment of patients in cardiogenic shock, and may fill a technological gap for patients who require acute circulatory support after VSD closure.Case presentationWe report our initial experience for two patients with post myocardial infarction VSD in the setting of cardiogenic shock supported with trans-aortic implantation Impella 5.5 SmartAssist. First patient had a posterior VSD with a left to right shunt (Qp/Qs ratio of 3.3), blood pressure 80/35 mmHg, right ventricle dysfunction, severe pulmonary arterial hypertension (an estimated systolic pulmonary artery pressure of 45 mmHg), and severe mitral valve regurgitation. Second patient was admitted for massive MI with large anterior VSD (Qp/Qs ratio of 2.8). Under cardiopulmonary bypass with cardioplegic arrest both patients underwent urgent VSD closure with trans-aortic implantation of the Impella. Minimal postoperative support was required. Patients were discharged on postoperative day 10 and 14 and remained well 3 months later. Follow-up echocardiogram showed no residual shunt.ConclusionsEarly surgical implantation of Impella 5.5 SmartAssist can prevent multiorgan dysfunction and stabilize the patients in cardiogenic shock with post-myocardial infarction VSD.

Highlights

ConclusionsSurgical implantation of Impella 5.5 SmartAssist can prevent multiorgan dysfunction and stabilize the patients in cardiogenic shock with post-myocardial infarction ventricular septal defect (VSD)
Despite advances in surgical techniques and aggressive therapy of post-infarction ventricular septal defect (VSD) with cardiogenic shock, the overall morbidity and mortality is frustratingly high
The Impella 5.5 with SmartAssist (Abiomed, Danvers, MA) is a surgically implanted temporary ventricular assist devices (VAD) recently approved by the FDA for treatment of patients in cardiogenic shock, and may fill a technology gap for perioperative patients who require acute circulatory support (Fig. 1a,b)

Summary

Conclusions

This is the first report of surgical implantation of the Impella 5.5 SmartAssist for patients with post-infarct VSD in cardiogenic shock. Our experience suggests the feasibility of using the Impella 5.5 SmartAssist to stabilize the patient, lowering pulmonary arterial and wedge pressure, reduce mitral valve incompetence and support the stunned ventricle with improvement of cardiac index after early surgical VSD closure. This strategy allows for heart recovery while maintaining distal organ perfusion. Our findings concerning the unique utility of the Impella 5.5 in the setting of cardiogenic shock in patients with post-MI VSD merit broader exploration.

Background

Discussion