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A 13-year obese female with suspected viral myocarditis presented with acute decompensated heart failure. Due to her body habitus, she was a poor candidate for immediate heart transplantation. A peripherally inserted left ventricular assist device (LVAD) was implanted via the right axillary artery. Following device insertion the patient experienced...
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Cardiac transplantation is the gold standard treatment for patients with advanced congestive heart failure that is refractory to maximal medical therapy. However, donor heart availability remains the major limiting factor, resulting in a large number of patients waiting long periods of time before transplantation. As a result, mechanical circulator...
Citations
... Previous versions of the Impella devices, including the Impella CP, Impella 2.5, and Impella 5.0, have been implemented in patients as young as 9 years old, with promising results. [1][2][3][4][5][6][7][8][9][10][11][12] However, use of the Impella 5.5 in the adolescent population is limited to a single case report describing a 14-year-old patient who received the Impella 5.5 as a bridge to heart transplant. 8 The Impella 5.5 not only provides greater circulatory support than past iterations of the device but also has different mechanical properties including a stiffer body and lack of pigtail to better facilitate axillary insertion. ...
Objectives
The Impella 5.5 has been successfully used in the adult population; however, safety and efficacy data in patients aged less than 18 years are limited.
Methods
Six pediatric patients, aged 13 to 16 years and weighing 45 to 113 kg, underwent axillary artery graft placement and attempted placement of the Impella 5.5 device at our institution between August 2020 and March 2023.
Results
Indications for implantation were heart failure secondary to myocarditis (2), rejection of prior orthotopic heart transplant, idiopathic dilated cardiomyopathy (2), and heart failure after transposition of the great arteries repair. Placement was unsuccessful in a 13.8-year-old female patient due to prohibitively acute angulation of the right subclavian artery, and venoarterial extracorporeal membrane oxygenation cannulation was performed via the axillary graft. In 5 patients with successful Impella 5.5 placement, median duration of support was 13.5 days (range, 7-42 days). One experienced cardiac arrest secondary to coagulation-associated device failure, requiring temporary HeartMate3 implantation. Four patients were bridged to transplant; 3 patients received a transplant directly from Impella 5.5, and 1 patient received a transplant after HeartMate3. The final patient received the HeartMate3 on Impella day 42 and is awaiting transplant.
Conclusions
Although exact size cutoffs and anatomy are still being determined, our experience provides a framework for use of the Impella 5.5 in adolescents.
... Impella for left-sided use was first reported in a pediatric patient in 2010, with subsequent case reports and case series detailing its use for primary circulatory support or to augment ECMO support in patients with myocarditis, cardiomyopathies, patients with post transplant graft rejection, or those undergoing highrisk catheterization procedures. [5][6][7][8][9] Over the years, we have used Impella for left-sided support in the pediatric population and relied on a variety of other means of paracorporeal right-sided support. Impella RP became more widely used in the adult population following the RECOVER RIGHT study, which showed the safety and efficacy of the device for acute RV failure. ...
Introduction:
Rejection with severe hemodynamic compromise is a significant source of morbidity and mortality for pediatric heart transplant patients. Traditionally, treatment of these patients includes inotropes and escalation to extracorporeal membrane oxygenation (ECMO) when necessary. There is increasing interest in using percutaneous ventricular assistive devices in the pediatric population as a less invasive alternative to ECMO. We report the largest case series to date of biventricular support using percutaneous Impella devices.
Methods:
Case series performed by retrospective chart review. Hemodynamics, left ventricular ejection fraction (LVEF), and indices of end organ function were collected before and after Impella placement.
Results:
A 14-year-old male, 18-year-old male, and 19-year-old female, all status post- heart transplant, presented with severely decreased biventricular function due to presumed clinical rejection, requiring maximal inotropic support without improvement. In all 3 cases, simultaneous Impella CP and RP devices were placed percutaneously. Pre-implantation, LVEF was 40%, 23% and 25%, respectively. Hemodynamics measured invasively prior to device placement showed elevated filling pressures. Adverse events while on support included bleeding, hemolysis, and right femoral arterial dissection during implantation. All patients were successfully weaned from the devices and survived to discharge. The average time of right-sided support and total support was 11 days and 13 days, respectively. After device removal, right sided pressures and echocardiographic measurements showed improvement in all patients.
Conclusion:
Bilateral Impella configuration (BiPella) is a viable option for temporary mechanical circulatory support in pediatric patients with significant graft dysfunction. This article is protected by copyright. All rights reserved.
... A recent analysis of the CVAD registry identified a 62% survival to discharge rate among myocarditis patients receiving Impella support. 35 Although all MCS devices improve cardiac output and blood pressure in patients with myocarditis they have different overall hemodynamic effects, particularly as they relate to impact on left ventricular (LV) unloading and pulmonary capillary wedge pressure (PCWP). There are limited data examining the implications of these differences on clinical outcomes. ...
Background:
Myocarditis may be associated with hemodynamic instability and portends a poor prognosis when associated with cardiogenic shock (CS). There are limited data available on the incidence of in-hospital mortality, CS, and utilization of mechanical circulatory support (MCS) devices in these patients.
Methods:
We queried the 2005-2014 National Inpatient Sample databases to identify all patients aged >18 years with myocarditis in the United States.
Results:
The number of reported cases of myocarditis per 1 million gradually increased from 95 in 2005 to 144 in 2014 (Pfor trend <.01). The trend and incidence of endomyocardial biopsy remained the same despite the increase in clinical diagnosis. Overall, in-hospital mortality was 4.43% of total admissions without a change in overall trend over the study period. We also observed a significant increase in the incidence of CS from 6.94% in 2005 to 11.99% in 2014 (Pfor trend <.01). There was a parallel increase in the utilization of advanced MCS devices during the same time period such as extracorporeal membrane oxygenation or percutaneous cardiopulmonary support (0.32% in 2005 to 2.1% in 2014; P< .01) and percutaneous ventricular assist devices such as Impella/tandem heart (0.176% in 2005 to 1.75% in 2014; P< .01).
Conclusion:
Although the incidence of myocarditis has increased in the last decade, the in-hospital mortality has remained the same despite increases in the incidence of CS, possibly reflecting the benefits of increased usage of advanced MCS devices. We noted that increasing age, presence of multiple comorbidities and CS were associated with an increase in in-patient mortality.
... LV stroke work represents the amount of LV work executed against the external environment, and with its reduction, it is expected that the LV is effectively unloaded and myocardial oxygen consumption is reduced. Based on the emerging concept that LV unloading may protect the heart from cardiac injury in acutely decompensated cardiac diseases [3,5,13,14], reliable methods to assess appropriate degree of unloading are required. Currently, invasive approaches such as myocardial oxygen consumption and pressure-volume relationship assessments are the gold standard to precisely evaluate the extent of LV work. ...
Non-invasive means of evaluating appropriate cardiac unloading remain to be established. We hypothesized that myocardial deformation assessed by echocardiographic speckle-tracking strain analysis can reliably estimate the degree of left ventricular (LV) unloading under mechanical circulatory support. A total of 24 Yorkshire pigs underwent Impella-mediated acute LV unloading 1–2 weeks after myocardial infarction (MI). Echocardiographic and invasive pressure-volume measurements were used to evaluate the degree of LV unloading. Pressure-volume analysis before and after LV unloading exhibited a significant decrease in stroke work (3399 ± 1440 to 1244 ± 659 mmHg ml, p < 0.001), suggesting reduced external cardiac work. Both longitudinal strain (− 14.6 ± 4.1% to − 10.6 ± 2.3%, p < 0.001) and circumferential strain (− 18.7 ± 6.1% to − 9.3 ± 3.5%, p < 0.001) decreased after LV unloading, and there were linear relationships between stroke work and echocardiographic longitudinal (r = − 0.61, p < 0.001) as well as circumferential strains (r = − 0.75, p < 0.001). Echocardiographic LV strain analysis offers a non-invasive assessment of LV unloading in subacute MI.
... Viral myocarditis (VMC) is a myocardial disease due to viral infection, which is an important etiology of acute decompensated heart failure in both pediatric and adult populations [1][2][3]. The prodromal symptomatic of VMC contained fever, respiratory and gastrointestinal symptoms [4]. ...
The main death reason is inflammatory response of myocardial tissue caused a sharp decline in myocardial contractility and heart failure. At present, viral myocarditis with heart failure is lack of effective and specific treatment. Basic and clinical studies have shown that intervention apoptosis is an effective way to prevent and cure heart failure. The mechanism of apoptosis is complex, endoplasmic reticulum (ER) stress is a new apoptotic signal transduction pathway was been found. In this study, the apoptosis could be increased in mice with CVB3 treatment. The ER stress related proteins GRP78, ATF4, CHOP were up-regulated in VMC. The mechanism of VMC regulated ERS induced apoptosis was identified. Calumenin protein could relieve ERS induced apoptosis in viral myocarditis in vivo. The DNA methylation of calumenin was analyzed in CON and VMC, however, we found VMC down-regulate the expression of calumenin unrelated with DNA methylation of calumenin.
Objectives:
The 2018 United Network for Organ Sharing allocation policy change has led to a significant increase in the use of mechanical circulatory support devices in patients listed for orthotopic heart transplantation. However, there has been a paucity of data regarding the newest generation Impella 5.5, which received FDA approval in 2019.
Methods:
The United Network for Organ Sharing registry was queried for all adults awaiting orthotopic heart transplantation who received Impella 5.5 support during their listing period. Waitlist, device, and early post-transplant outcomes were assessed.
Results:
A total of 464 patients received Impella 5.5 support during their listing period with a median waitlist time of 19 days. Among them, 402 (87%) patients were ultimately transplanted, with 378 (81%) being directly bridged to transplant with the device. Waitlist death (7%) and clinical deterioration (5%) were the most common reasons for waitlist removal. Device complications and failure were uncommon (<5%). The most common post-transplant complication was acute kidney injury requiring dialysis (16%). Survival at 1-year post-transplant survival was 89.5%.
Conclusion:
Since its approval, the Impella 5.5 has been increasingly used as a bridge to transplant. This analysis demonstrates robust waitlist and post-transplant outcomes with minimal device-related and postoperative complications.
Acute Cardiac Unloading and Recovery - Proceedings
Aims:
Haemodynamic load induces cardiac remodelling via mechano-transduction pathways, which can further trigger inflammatory responses. We hypothesized that particularly in an inflammatory disorder such as myocarditis, a therapeutic strategy is required which, in addition to providing adequate circulatory support, unloads the left ventricle, decreases cardiac wall stress, and mitigates inflammatory responses.
Methods and results:
Axial flow pumps such as the Impella systems comply with these requirements. Here, we report a potential mode-of-action of prolonged Impella support (PROPELLA concept) in fulminant myocarditis, including a decrease in cardiac immune cell presence, and integrin α1, α5, α6, α10 and β6 expression during unloading.
Conclusion:
PROPELLA may provide benefits beyond its primary function of mechanical circulatory support in the form of additional disease-altering effects, which may contribute to enhanced myocardial recovery/remission in patients with chronic fulminant myocarditis.
