Impella Support for Surgical Ventricular Septal Defect Repair

Abstract

Acute postinfarct ventricular septal defect (VSD) is associated with high mortality due to a combination of cardiogenic shock and a complex repair in recently infarcted fragile myocardium.1 Although the Impella heart pump is established as support for cardiogenic shock, it is relatively contraindicated in postinfarct VSD because of potential right-to-left shunt or stroke due to VSD tissue–related embolus. On autopsy, early repair is technically difficult due to tissue friability and as a result, 38% of surgically repaired patients have evidence of recurrent interventricular septal rupture.2 Delayed surgical repair (>7 days) is associated with superior survival—54% after 7 days versus 18% prior—but hemodynamic instability may prevent delay.3 Case reports have shown successful early left ventricular unloading with Impella patients with acute postinfarct VSD before surgical repair.4,5 We discuss our algorithm for pre-repair Impella support in which we stratify pre-repair support based on the Qp/Qs ratio. For VSD with Qp/Qs >2.5, we use a preoperative Impella heart pump and have not demonstrated reversal in the left-to-right shunt on echocardiography and/or stroke. Our findings are consistent with theoretical models of unloading as demonstrated by shifts in pressure–volume loops.6

Simple, Swift, and Safe for Managing Post Infarction Ventricular Septal Defects

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We want to thank Dr. Pavlov for his interest in our case series on Post infarction ventricular septal rupture (PIVSR) and congratulate him on the excellent outcome of his own patient. 1 Regarding the first comment, we agree that PIVSR are heterogeneous. Like Dr. Pavlov, we also delay repair for reasons outlined.

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“…We want to thank Dr. Pavlov for his interest in our case series on Post infarction ventricular septal rupture (PIVSR) and congratulate him on the excellent outcome of his own patient. 1…”

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].…”

“…The delay of surgery is justified by better success rates for operative VSD closure in literature as the tissue friability is reduced. 5,6…”

Support for Postinfarction Ventricular Septal Rupture: Keep it Simple, Swift, and Safe

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To the Editor:I read with much interest the case series by Ruiz Duque et al 1 on four patients with surgical repair of postinfarction ventricular septal rupture (PIVSR) treated with Impella. The authors propose to use Impella in patients with Qp/Qs >2.5.

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