Successful surgical employment of Impella recovery system for right ventricular failure after previous aortic valve replacement

Abstract

A 58-year-old woman underwent aortic valve replacement. On the second postoperative day the patient referred a sharply chest pain, and an emergent coronary angiography revealed total occlusion of the right coronary artery. An intra-aortic ballon pump was placed and the patient underwent emergent off-pump coronary revascularization of the right coronary artery. Five hours later, due to unstable hemodynamic the extracorporeal membrane oxygenation was implanted without improvement of the right ventricular (RV) function. Then we decided to implant the Impella Right Direct (RD). After 9 days of Impella’s insertion the RV was recovered and the device was successfully explanted. After 16 days of Impella explanted the patient was discharged. This case suggest that implantation of Impella RD is clinically feasible, associated with hemodynamic improvement, and facilitate successful bridge-to-recovery in patients with post-cardiotomy RV failure due to myocardial infarction unresponsive to coronary artery bypass grafting, maximal medical therapy, contrapulsation and extracorporeal membrane oxygenation.

Percutaneous Coronary Intervention Through a Retrograde Approach in Complete Occlusion of the Coronary Ostium Following Surgical Aortic Valve Replacement

“…Several pathophysiologic mechanisms have been suggested, and these include coronary spasm, debris/ thrombus embolization from the aortic valve or wall, [5][6][7] and intraoperative iatrogenic causes, such as extraluminal compression (e.g., the surgical material, the suture used to close, hematoma) 8) or vessel transection (e.g., vessel kinking). 4,9) The usual symptoms and clinical findings of COS after SAVR include the development of unstable angina, which could be treated by either CABG 1,2) or PCI. 4,8,10) Advancements in the techniques and instruments over the past 20 years have led to the increased utility of PCI to successfully treat COS, and favorable outcomes have been achieved compared to early repeat surgery.…”

“…In general, such CABG in these patients might result in a high operative mortality rate and a poor long-term outcome due to the risk of severe bleeding on oral anticoagulation mediations, and the close temporal relationship of the redo cardiac surgery with the graft sites next to the region of the previous operation. Krakulli et al 2) reported a case of a patient who needed emergent CABG for the treatment of COCO following SAVR. However, the patient appeared to have a poor response to emergent CABG and shortly thereafter developed unstable hemodynamics due to right ventricular failure.…”

“…However, for a complete occlusion of the coronary ostium (COCO), CABG is the typical treatment strategy due to the challenge of guiding catheter (GC) engagement. 1,2) Herein, we presented a case of a patient with COCO following SAVR who underwent successful PCI through a retrograde approach.…”