Case Review, Patient Management, Protected PCI
LVEF Improvement After Complex High-Risk Case with Impella® Support
Rustem Dautov, MD, FRACP, PhD describes a complex high-risk indicated patient case in which the Impella CP® heart pump played a vital role. It was a case with “several risk factors and a few curve balls,” notes interviewer Shon Chakrabarti, MD.
Dr. Dautov, an interventional cardiologist at The Prince Charles Hospital in Brisbane, Australia, successfully treated a 91-year-old patient with several risk factors, low hemodynamic reserve in the setting of severe aortic stenosis, and no surgical bailout options. Angiography revealed complex anatomy, calcified distal left main and circumflex, and proximal LAD disease. He then performed rotablation of the left main, LAD, and left main circumflex. After ballooning of the LAD, he deployed a proximal LAD stent and a separate stent to the left main circumflex.
While positioning the second stent, Dr. Dautov saw evidence of bleeding, but he needed to complete stenting before fixing the perforation. Echo was ordered. He did 4.0 balloon inflation, gradually moving from the proximal circumflex to the ostium to identify the location of the perforation. Only inflating the balloon across the ostium of the circumflex stopped the bleeding.
Dr. Dautov performed balloon tamponade, but the patient did not tolerate it well and it didn’t stop the bleeding. Bleeding worsened and the patient received blood auto-transfusion. Eventually, despite Impella support, the patient experienced nausea and vomiting and a drop in blood pressure as he deployed a covered stent. Working quickly, Dr. Dautov was able to complete the case and the patient recovered. “So it was, I guess, a complicated complex high-risk procedure,” he tells Dr. Chakrabarti.
“Impella allowed me to feel comfortable in this situation,” Dr. Dautov explains, “Even though the patient started to become unwell, I felt comfortable doing step by step my plan of helping this patient.” During rotablation, the patient flatlined. Dr. Dautov emphasizes that with the complications, if the case had been done without Impella, the case likely would have had a fatal outcome. Instead, with Impella support, the case was successful and the patient’s LVEF improved from 35% to 55% at 5-week follow up. The patient was able to undergo further treatment and Dr. Dautov reports that the patient was doing well at 7 months.