Abstract:Background:
Cardiogenic shock due to acute severe mitral regurgitation is characterized by multiple organ failure and acute pulmonary edema, leading to a high risk of mortality.
Methods and Results:
We report on a patient with acute, severe mitral regurgitation complicated by cardiogenic shock, refractory to both inotrope treatment and intra-aortic balloon pump support. The patient was successfully bridged to surgery with an Impella CP, a percutaneous left ventricular a… Show more
“…Baseline hemodynamics in patients with trace/mild FMR were not significantly different from patients with moderate and moderate-tosevere/severe FMR. At 24 hours post-Impella implant, there was a significant decrease in CVP (12 [8-14] to 9 [7][8][9][10][11], p ¼ 0.012), a significant decrease in pulmonary artery diastolic pressure (PADP; 25 [19][20][21][22][23][24][25][26][27] to 18 [14-21], p ¼ 0.002) and pulmonary capillary wedge pressure (22 [16][17][18][19][20][21][22][23][24][25][26] to 17 [10][11][12][13][14][15][16][17][18][19][20], p ¼ 0.008), a significant drop in systemic vascular resistance (1541 [1225-1914] to 960 [864-1183], p 0.001), a significant decrease in serum lactate levels (1.9 [1.2-2.7] to 1.3 [1-1.7], p ¼ 0.046), and a significant decrease in vasoactive-inotrope score (VIS; 12 [7][8][9][10][11][12][13][14][15][16][17][18]…”
Section: Resultsmentioning
confidence: 99%
“…This study also found that neither baseline nor residual MR affected survival at 24 months post-LVAD implant. 13 The Impella 5.5 can provide flows comparable to durable LVADs, but only small case series have examined the use of Impella in the setting of CS with concomitant severe MR. 9,10 In our small, retrospective cohort, we make 3 important observations: (1) the Impella 5.5 did not appear to acutely (within 24 hours) ameliorate moderate or greater FMR; (2) Impella 5.5 did provide significant left ventricular unloading as evidenced by a reduction in intracardiac filling pressures and lactate clearance as well as a significant decrease in systemic vascular resistance and vasoactive-inotrope score (Table 1); and (3) a significant proportion of patients in our cohort (42%) experienced NHR on Impella 5.5 support, regardless of baseline/residual FMR severity (Figure 1). These observations were made across the entire cohort, regardless of baseline severity of FMR.…”
Section: Discussionmentioning
confidence: 99%
“… 6 , 7 The Impella device (Abiomed, Danvers, Massachusetts), in contrast, has been shown not to impact the integrity of the mitral valve apparatus, 8 but only a few cases of its use in the presence of acute, severe ischemic MR have been reported. 9 , 10 There is no description of the impact of Impella device on hemodynamic response when used in combination with preexisting FMR. We sought to examine the hemodynamic response to Impella 5.5 in patients with heart failure–related CS (HF-CS) and concomitant FMR.…”
“…Baseline hemodynamics in patients with trace/mild FMR were not significantly different from patients with moderate and moderate-tosevere/severe FMR. At 24 hours post-Impella implant, there was a significant decrease in CVP (12 [8-14] to 9 [7][8][9][10][11], p ¼ 0.012), a significant decrease in pulmonary artery diastolic pressure (PADP; 25 [19][20][21][22][23][24][25][26][27] to 18 [14-21], p ¼ 0.002) and pulmonary capillary wedge pressure (22 [16][17][18][19][20][21][22][23][24][25][26] to 17 [10][11][12][13][14][15][16][17][18][19][20], p ¼ 0.008), a significant drop in systemic vascular resistance (1541 [1225-1914] to 960 [864-1183], p 0.001), a significant decrease in serum lactate levels (1.9 [1.2-2.7] to 1.3 [1-1.7], p ¼ 0.046), and a significant decrease in vasoactive-inotrope score (VIS; 12 [7][8][9][10][11][12][13][14][15][16][17][18]…”
Section: Resultsmentioning
confidence: 99%
“…This study also found that neither baseline nor residual MR affected survival at 24 months post-LVAD implant. 13 The Impella 5.5 can provide flows comparable to durable LVADs, but only small case series have examined the use of Impella in the setting of CS with concomitant severe MR. 9,10 In our small, retrospective cohort, we make 3 important observations: (1) the Impella 5.5 did not appear to acutely (within 24 hours) ameliorate moderate or greater FMR; (2) Impella 5.5 did provide significant left ventricular unloading as evidenced by a reduction in intracardiac filling pressures and lactate clearance as well as a significant decrease in systemic vascular resistance and vasoactive-inotrope score (Table 1); and (3) a significant proportion of patients in our cohort (42%) experienced NHR on Impella 5.5 support, regardless of baseline/residual FMR severity (Figure 1). These observations were made across the entire cohort, regardless of baseline severity of FMR.…”
Section: Discussionmentioning
confidence: 99%
“… 6 , 7 The Impella device (Abiomed, Danvers, Massachusetts), in contrast, has been shown not to impact the integrity of the mitral valve apparatus, 8 but only a few cases of its use in the presence of acute, severe ischemic MR have been reported. 9 , 10 There is no description of the impact of Impella device on hemodynamic response when used in combination with preexisting FMR. We sought to examine the hemodynamic response to Impella 5.5 in patients with heart failure–related CS (HF-CS) and concomitant FMR.…”
“…The IABP provides a rescue strategy for afterload reduction when haemodynamic instability limits the use of vasodilators [ 43 ]. VA ECMO and Impella devices are emerging alternatives to provide temporary mechanical support as a bridge to surgical intervention in acute MR [ 44 , 45 ]. Fig.…”
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
“…1 In the United States, the use of Impella devices is increasing for multiple indications. 2,3 An LV thrombus is a contraindication for inserting any Impella device. 4 However, thrombus formation can occur after Impella support is initiated by a combination of profound impairment of LV contractility, a poor flow state at the time of Impella 5.5 insertion, turbulent flow in the LV, or the thrombogenic nature of the device.…”
The Impella 5.5® (Abiomed, Danvers, MA, USA) is a microaxial flow pump that promotes left ventricular unloading and improves end-organ perfusion before durable left ventricular assist device (LVAD) implantation. Thrombus formation after Impella 5.5 insertion can occur and represents a significant challenge to device explantation. Durable LVAD implantation is typically performed without aortic cross-clamping, so a dislodged thrombus can potentially embolize and lead to catastrophic events. We describe our technique to safely explant an Impella 5.5 in patients who develop a thrombus on the inflow portion of the device before surgical LVAD implantation.
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