Early cardiac unloading with ImpellaCP™ in acute myocardial infarction with ventricular septal defect

Abstract

Despite a relative contraindication, mechanical support with Impella™ left ventricular assist device has already been described for ischaemic ventricular septal defect treatment, either as a bridge to surgery, as intraoperative mechanical haemodynamic support, or to ensure intraprocedural haemodynamic stability during device closure. We describe two cases of ventricular septal defect complicating acute myocardial infarction, where the percutaneous ImpellaCP was implanted early (differently than previously described) with the aim of preventing haemodynamic instability, while deferring surgical repair. We present a report of haemodynamic, echocardiographic, biochemical, and clinical data of two consecutive cases of ImpellaCP use, within a minimally invasive monitoring and therapeutic approach. In two cases of subacute myocardial infarction-related ventricular septal defect not amenable to percutaneous device closure, the use ImpellaCP was successful: it was followed by effective and rapid right and left ventricular unloading, by major haemodynamic instability prevention and protection from systemic venous congestion, from kidney and splanchnic organ failures. This allowed bridging to appropriately timed surgical repair. These cases suggest a potentially effective, clinically grounded strategy in the early management of ischaemic ventricular septal defect patients, with the aim of deferring surgery beyond the safer 7 days cutoff associated with a lower perioperative mortality.

Keywords: Acute heart failure; Acute myocardial infarction mechanical complication; Impella; Left ventricular assist device; Ventricular septal defect.

Figure 1

(A) Case 1: modified transthoracic echocardiography (TTE) parasternal long axis view showing mid‐distal anterior ventricular septal defect (VSD, arrow). (B) Case 1: same TTE view, with left‐to‐right shunt portrayed as high‐speed turbulent color jet through the VSD. (C) Case 1: apical 4 chamber view, end‐diastole, showing a dilated right ventricle (RV). Measured RV indexed end‐diastolic area was 13.4 cm²/m². (D) Case 1: TTE subcostal inferior vena cava (IVC) view showing a dilated IVC (end expiratory diameter 22 mm). Inspiratory IVC size reduction was also measured as being 5%. (E) Case 1: same view as in panel C, immediately after ImpellaCP left ventricular assist device implant. RV size significantly reduced (measured RV indexed end‐diastolic area was 10.6 cm²/m²⁾. (F) Case 1: same view as in panel D, immediately after left ventricular assist device implant. IVC end expiratory size significantly reduced to a size of 17 mm. IVC size inspiratory reduction also improved, becoming equal to 20%. (G) Case 2: TTE subcostal long axis view showing a basal inferoseptal VSD (arrow). (H) Case 2: TTE parasternal basal short axis view, showing a high flow turbulent left‐to‐right color flow through the inferobasal VSD.