ECMO and Impella Support Strategies as a Bridge to Surgical Repair of Post-Infarction Ventricular Septal Rupture

Abstract

Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.

A new dimension to the STEMI-related mortality risk seen in the COVID-19 pandemic era

“…Delay between electrocardiographic documentation of STEMI and subsequent development of VSR ( Table 2 ). Twenty patients (13 male) belonged to this category [ [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] ]. Their mean age was 66.…”

“…Conversely, in the presence of severe hypotension, the systolic murmur of VSR “may be difficult to identify because turbulent flow across the defect is reduced” [ 61 ], and the same might also be true of the systolic murmur of PMR [ 62 ]. Clinicians should also be especially vigilant for “stepwise” evolution of VSR [ [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] ], whereby a patient with delayed presentation of STEMI initially presents without clinical or echocardiographic stigmata of VSR but subsequently experiences hypotension and/or increasing breathlessness signalling onset of VSR [ [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] ]. The onset of VSR, in such cases, is typically associated with new-onset pansystolic murmur.…”

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

“…Some studies, including case reports and small clinical series, suggested that VA-ECMO is a strategy to improve hemodynamic derangements and allows for delayed surgical repair. [15] However, the left ventricular afterload is increased, and this could increase the shunt fraction in PIVSR. The feasibility and safety of VA-ECMO in PIVSR need more studies to be confirmed.…”

Implanting Impella 5.5 under Local Anesthesia

“…Six days after surgery the Impella was explanted in the operating theatre. The delay of surgery is justified by better success rates for operative VSD closure in literature as the tissue friability is reduced [5] [6].…”