Case Review, Complete Revascularization, Unloading, Protected PCI
Impella® Unloading and Coronary Reperfusion Save a Heart and a Life
Impella unloading and coronary reperfusion saved the heart and life of this 50-year-old man who was found unconscious by his grandson. He was emergently taken to the cardiac catheterization lab where a pre-PCI angiogram and LV ventriculography (LV gram) revealed multivessel disease involving the LAD, LCX, and OM. His ejection fraction was 10% and LVEDP 32 mmHg. An Impella CP® with SmartAssist® was placed while awaiting a CT surgery consult. However, the patient was turned down for surgery and transferred to the ICU for continued supportive care. With the goal of supporting heart recovery efforts while awaiting transfer to another facility, the patient was escalated to Impella 5.5® with SmartAssist®.
The interventional cardiologist and heart failure physician at the receiving hospitals reviewed films and recommended hospice care. The heart team, however, recommended a repeat angiogram since the patient had been supported with Impella 5.5 with SmartAssist with active unloading for more than 5 days. The repeat angiogram showed that LCX and OM vessels were evident due to improved coronary perfusion.
The patient underwent another PCI with Impella 5.5 with SmartAssist support and the interventional cardiologist was able to revascularize the LCX and OM. A subsequent PCI after 2 more days of Impella support resulted in successful stenting of the LAD.
Following complete revascularization of diseased vessels, the patient was successfully weaned from Impella 5.5 with SmartAssist support, and the device was explanted without any complications. A follow-up echo revealed that the patient’s ejection fraction had improved from 10% to approximately 45%. Thus, rather than being discharged to hospice care with an ejection fraction of 10%, this patient achieved complete revascularization and native heart recovery with Impella support.
For more information about Impella unloading the left ventricle and increasing coronary perfusion within stenotic lesions, refer to “Beyond the coronary arteries, should we be shifting our focus to mechanical circulatory support in patients with acute myocardial infarction and cardiogenic shock” by M. Babar Basir in the July 2020 issue of Cardiovascular Revascularization Medicine and “Effects of Impella on coronary perfusion in patients with critical coronary artery stenosis” by Mohammad Alqarqas et al. in the April 2018 issue of Circulation: Cardiovascular Interventions.