Impella RP as a bridge to cardiac transplant for refractory late right ventricular failure in setting of left ventricular assist device

Abstract

Right ventricular (RV) failure remains a major complication after surgical implantation of a left ventricular assist device (LVAD). While the use of a percutaneous RV assist device has been described as a short-term bridge to recovery in end-stage heart failure patients with early post-operative RV failure after index LVAD implant, management of refractory late RV failure remains challenging in these patients. We report the first successful case of extended Impella RP use as a safe and effective bridge to orthotopic heart transplant in an LVAD patient with refractory, haemodynamically significant late RV failure. The Impella RP provided support for 37 days. Haemodynamically intolerant arrhythmia precluded use of inotropic support. No adverse complications related to percutaneous Impella RP support were seen. We also review potential considerations for mechanical circulatory support strategies in this setting: central RV assist device cannulation requires sternotomy incision that can impact subsequent cardiac surgeries, while percutaneous Protek Duo insertion requires adequate vessel size and patency. With an LVAD in situ, veno-arterial extracorporeal membrane oxygenation was not considered for isolated RV support in this case. The patient is currently over 6 months post-orthotopic heart transplant.

Bridge to transplantation from mechanical circulatory support: a narrative review

“…Varian et al (22) successfully used the Impella 5.0 and the Impella RP as a BTT therapy in a patient with rapidly progressive cardiac sarcoidosis. Randhawa et al (23) reported on the first extended use of the Impella RP in a patient with a durable left ventricular assist device (LVAD) as a BTT strategy. The patient was supported by the Impella RP for 37 days and was successfully bridged to transplantation without any device-related complications.…”

Patient selection for heart transplant: balancing risk

“…, [16][17][18]. Since the 2018 UNOS heart allocation update, the use of temporary tMCS including intra-aortic balloon pumps (IABP), percutaneous ventricular assist devices (Impella), and extracorporeal membrane oxygenation (ECMO) has significantly increased and has been associated with an increase in waitlist survival [19][20][21][22][23][24]. ECMO use as bridge-to-transplantation (BTT) has increased fourfold [25].…”

“…Temporary mechanical circulatory support (tMCS) is recommended to stabilize patients in cardiogenic shock to manage critical, reversible end-organ hypoperfusion [13,14 ▪▪ ,15 ▪ ,16–18]. Since the 2018 UNOS heart allocation update, the use of temporary tMCS including intra-aortic balloon pumps (IABP), percutaneous ventricular assist devices (Impella), and extra-corporeal membrane oxygenation (ECMO) has significantly increased and has been associated with an increase in waitlist survival [19–24]. ECMO use as bridge-to-transplantation (BTT) has increased four-fold [25].…”

First‐in‐man successful use of the SPECTRUM percutaneous dual‐stage right ventricle and right atrium to pulmonary artery ventricular assist device

“…Over the past decade, several minimally invasive mechanical support devices have been introduced to support the right ventricle (RV) 1–3 . Percutaneous options are divided into an intracorporeal axial flow pumps and circuits using extracorporeal centrifugal pumps 4,5 . Centrifugal pump‐driven circuits require the cannulas to be placed surgically in central great vessels or percutaneously in the peripheral vessels.…”

“…[1][2][3] Percutaneous options are divided into an intracorporeal axial flow pumps and circuits using extracorporeal centrifugal pumps. 4,5 Centrifugal pump-driven circuits require the cannulas to be placed surgically in central great vessels or percutaneously in the peripheral vessels. Percutaneous cannulas are easy to implant, minimally invasive, and treat ARVF rapidly.…”