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Surgical Strategies Using Impella 5.5 And Impella Rp Flex Before And After Post-infarct Ventricular Septal Defect Repair
Hiroyuki Tsukui1, Daisuke Kaneyuki2.
1Johns Hopkins Hospital, Baltimore, MD, USA, 2Independence Health System Westmoreland Hospital, Greensburg, PA, USA.
BACKGROUND:Early surgical repair of post-myocardial infarction ventricular septal defect (VSD) is generally recommended because of the rapid progression of heart failure and multi-organ dysfunction. However, in the acute phase, myocardial necrosis is not yet consolidated, making it difficult to determine the margins for safe resection, and the fragility of the tissue increases the risk of residual shunt after closure. Therefore, the concept of delayed surgery has gained attention. We report a case in which the Impella 5.5 and Impella RP Flex devices were used effectively before and after VSD repair, allowing stabilization, delayed intervention, and successful postoperative management.
METHODS:A 59-year-old man presented with chest pressure, dyspnea, and edema. Emergent catheterization revealed complete thromboembolic occlusion of the proximal right coronary artery and severe stenosis of the obtuse marginal branch. After thrombectomy and stent placement, echocardiography demonstrated a 15-mm VSD. Because the patient showed worsening heart failure and multi-organ dysfunction, emergency VSD repair was considered inappropriate. An Impella 5.5 was inserted percutaneously to stabilize hemodynamics and allow recovery of end-organ function prior to definitive repair.
RESULTS:The patient was extubated the day after Impella 5.5 insertion and no longer required inotropes. On day 13, VSD closure and coronary artery bypass grafting were performed. At surgery, the necrotic myocardium around the VSD had stabilized, allowing secure closure using a double-patch technique via right ventriculotomy. Weaning from cardiopulmonary bypass was achieved under Impella 5.5 support, and intraoperative echocardiography confirmed complete closure without residual shunt. After closing chest, the patient developed right ventricular failure, and an Impella RP Flex was inserted. Combined left and right ventricular support achieved hemodynamic stability, enabling extubation the following day. The Impella RP Flex and Impella 5.5 were removed on postoperative days 5 and 9, respectively, and the patient was discharged on postoperative day 16.
CONCLUSIONS:Early Impella 5.5 insertion can provide hemodynamic stabilization and sufficient time for recovery of heart failure and organ dysfunction, facilitating safe delayed VSD repair with reduced risk of residual shunt. For anticipated postoperative biventricular failure, continued Impella 5.5 support and selective use of Impella RP Flex offer an effective strategy for ensuring adequate cardiac recovery.
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