Case Review, Insertion, Surgical Applications
AATS 2021 Master Surgery Class: Axillary and Direct Aortic Insertion of Impella 5.5® with SmartAssist®
Watch as three eminent cardiac surgeons demonstrate axillary and direct aortic insertion of the Impella 5.5® with SmartAssist®. These three presentations, as well as the Q&A session that follows, were recorded in 2021 as a Master Class for the American Association for Thoracic Surgery (AATS).
Masaki Funamoto, MD, PhD, a cardiothoracic surgeon at Methodist Hospital in San Antonio, discusses axillary artery access. He begins by describing the anatomy around the axillary artery and important anatomic landmarks for incision. After making the incision, he shows how to locate and expose the axillary artery, make the incision in the artery, and attach the graft for insertion. He then inserts the Impella 5.5 with SmartAssist, trims the graft, secures the graft in the incision, and closes the incision.
Raymond Lee, MD, a cardiac surgeon from Keck Medical School at the University of Southern California in Los Angeles, describes open-chest insertion of Impella 5.5 with SmartAssist using the direct ascending aortic root approach. He places Impella 5.5 with SmartAssist directly across the aortic valve with echo guidance and weans the patient off cardiopulmonary bypass onto Impella® support. He uses a soft occlusion clamp on the graft anastomosis junction to hold Impella in position so he can focus on weaning the patient off bypass before trimming the graft. Dr. Lee discusses strategies for getting Impella 5.5 with SmartAssist across the aortic valve, trimming the graft, and securing Impella 5.5 with SmartAssist at the skin exit site. The innovative manner in which he exteriorizes Impella 5.5 with SmartAssist allows him to remove the catheter at bedside with the patient awake and under local anesthesia.
Duc Thinh Pham, MD, FACS, from Northwestern University in Chicago, demonstrates his refined technique for axillary insertion of Impella 5.5 with SmartAssist using the case of a 56-year-old male readmitted for acute heart failure and volume overload. Dr. Pham notes the importance of ensuring 1.5 to 2 cm of exposed artery for adequate arteriotomy length. He explains that after the anastomosis is complete, he prefers to tunnel the graft through a counter-incision to help decrease the risk of infection in the axillary incision and anastomosis and to facilitate removal or exchange of Impella. He highlights that while there is a tendency to put the bend of the Impella 5.5 with SmartAssist in the same contour as the axillary artery during insertion, he recommends putting the bend opposite of the contour of the axillary artery so that when the Impella 5.5 with SmartAssist crosses the aortic valve and enters the ventricle it will flip away from the mitral valve as it sits inside the ventricle. He also highlights that the dilator sheath has a lubricant that will open as well as lubricate the valve to facilitate entry of the Impella 5.5 with SmartAssist.
Q&A session: Masahiro Ono, MD, PhD, a heart transplant and mechanical circulatory support surgeon, joins Dr. Funamoto and Dr. Lee in a Q&A session facilitated by Daniel Raess, MD, FACC, FACS. Topics include when to use axillary insertion over direct aortic insertion, use of Impella 5.5 with SmartAssist for unloading the LV during ECMO support, and key differences between the Impella 5.5 with SmartAssist and Impella 5.0®.