P103: Impella 5.5: An Alternative Therapy for Complex Patients with WHO Class II Pulmonary Hypertension

Abstract

Background: Pulmonary hypertension (PH) is associated with advanced heart failure, which results in a worse prognosis, limits candidacy for heart transplant (HTx), and increases complications after HTx. Heart/lung transplant may overcome the complications of PH. However, the survival duration of patients after dual organ transplant is significantly shorter than HTx alone. We present a case of cardiogenic shock and severe PH in which we used temporary mechanical circulatory support with an Impella 5.5 to optimize PH successfully. Case: A 54-year-old female blood group O after workup and review by our selection committee was listed as status 6 for HTx due to non-ischemic cardiomyopathy. Right heart catheterization showed an RA of 15 mmHg, PA 75/37 (50), and PCWP 32. The Fick cardiac index was 1.2L/min/m2 with a PA saturation of 52% and PVR of 5.2 WU. On 3mcg/kg/min of Nipride, mPA was 38, and PCWP of 26. Concern for progression to fixed PH despite milrinone led our team to proceed with Impella 5.5 placement. Her PH improved after Impella to PA 51/15 (27) and PCWP of 15 with a PVR of 2.7 WU. She underwent a successful HTx and remains alive at 2 years without recurrent pulmonary hypertension. Decision-making: In a complex patient with WHO class II PH (unrelated to mitral valve disease), therefore not a candidate for therapies such as MitraClip, LV unloading is known to optimize multi-organ function and reduce PH. Traditionally the inability of sustained reversal of PH (mPA <40, PVR <3.5wu) with medical management is a contraindication for HTx. Given our patient’s choice to decline LVAD placement, our heart team felt it prudent to use the Impella 5.5 in an attempt to unload the LV fully. Conclusion: Our case shows the potential impact the Impella 5.5 device can have on patients with severe pulmonary hypertension. The implication of this therapy in avoiding heart/lung transplant, and potentially improving survival, should be explored.