Systemic Right Ventricle Mechanical Support with Impella 5.5 as a Bridge to Cardiac Transplantation

Abstract

<h3>Introduction</h3> A 39-year-old man with Senning atrial switch for dextro-transposition of the great arteries (d-TGA) presented with systemic right ventricle (RV) failure and cardiogenic shock. He had Impella 5.5 percutaneous mechanical support for his systemic RV and received cardiac transplantation 42 days later. To our knowledge, this has not been previously reported in the literature. <h3>Case Report</h3> A 39-year-old man with Senning atrial switch for d-TGA and long-standing systemic RV dysfunction on heart failure medical and resynchronization therapy was transferred for cardiogenic shock. Diuresis was unsuccessfully attempted with a furosemide drip, so inotropes and evaluation for advanced heart failure therapies were initiated. His condition initially improved, but on hospital day 8, he had a ventricular fibrillation cardiac arrest, requiring cardiopulmonary resuscitation and emergent femoral intra-aortic balloon pump (IABP) placement. Right heart catheterization showed cardiac index of 2.16 L/min/m^2 on milrinone, dobutamine, and IABP. He continued to clinically deteriorate. After multidisciplinary discussions, an axillary Impella 5.5 device was placed under fluoroscopic and TEE guidance. The device could not be rotated posteriorly away from the RV free wall due to the opposing posterior orientation of the atrioventricular valve and anterior course of the innominate artery (figure). However, there was significant hemodynamic improvement and no arrhythmias, so device was secured. He was listed for heart transplantation as UNOS Status 2. Forty-two days after Impella placement, a suitable donor heart became available. He underwent successful transplant with initial biopsy showing no rejection. He was discharged on post-operative day 12 and continues to do well as an outpatient. <h3>Summary</h3> Impella 5.5 device implantation in the systemic RV is a feasible strategy for patients with d-TGA and atrial switch awaiting durable VAD or transplant.