Aortic insufficiency associated with Impella that required surgical intervention upon implantation of the durable left ventricular assist device

Abstract

The Impella is an axial-flow percutaneous ventricular assist device for cardiogenic shock. In this report, we describe two patients who developed aortic insufficiency (AI) associated with Impella and required surgical intervention upon implantation of the durable left ventricular assist device (LVAD). Both patients presented with cardiogenic shock and underwent insertion of Impella 5.0 as a bridge to decision. The cardiac function in these patients did not improve and obtaining approval for heart transplantation required time. They were managed with Impella for 91 and 98 days, respectively. In both cases, moderate AI that was not present before Impella insertion was observed when the Impella was removed. Therefore, we performed aortic valve closure to control the AI during durable LVAD implantation. In patients with durable LVAD implantation, AI may occur and progress after the operation in several cases. Aortic valve surgery is often performed to prevent deterioration of AI, especially in patients with AI before the surgery. Hence, AI is an important complication following Impella device implantation as a bridge to decision. Careful observation of AI is essential when the Impella is removed as the evaluation of AI by echocardiogram during Impella management is cumbersome because of device-generated artifacts.

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Correspondence to Toru Kondo.

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T. O. received lecture fees from Ono Yakuhin, Medtronics, and Otsuka, and received research grants from Ono Yakuhin, Bayer, Daiichi-Sankyo, and Amgen Astellas (not in connection with the submitted work). A. U. received research grants from TERUMO, Edwards Lifesciences, JAPAN LIFELINE, Mitsubishi Tanabe, Medtronic Japan, Senko medical instrument, St. Jude Medical, Pfizer, Daiichi-Sankyo, iCorNet, Trestech, and NIPRO. T. M. received lecture fees and unrestricted research grants from the Department of Cardiology at Nagoya University Graduate School of Medicine, Bayer, Daiichi-Sankyo, Dainippon Sumitomo, Kowa, MSD, Mitsubishi Tanabe, Boehringer Ingelheim, Novartis, Pfizer, Sanofi-Aventis, Takeda, Astellas, Otsuka, and Teijin.

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Movie 1: Twenty-nine days after Impella 5.0 insertion, transthoracic echocardiogram revealed slight aortic insufficiency in case 1 (MPG 3180 kb)

Movie 2: A defect between right coronary cusp and non-coronary cusp became evident on transesophageal echocardiogram when Impella was removed in case 1 (MPG 2876 kb)

Movie 3: Transesophageal echocardiogram detected moderate aortic insufficiency when Impella was removed in case 1 (MPG 3390 kb)

Movie 4: Transthoracic echocardiogram revealed trivial aortic insufficiency one day after the central aortic valve closure at durable left ventricular assist device implantation in case 1 (MPG 3278 kb)

Movie 5: Transthoracic echocardiogram showed no obvious regurgitation flow just after Impella 5.0 insertion in case 2 (MPG 4786 kb)

Movie 6: Transthoracic echocardiogram detected moderate aortic insufficiency when Impella was transiently removed in case 2 (MPG 5298 kb)

Movie 7: Transthoracic echocardiogram showed no obvious aortic insufficiency two days after the central aortic valve closure at durable left ventricular implantation in case 2 (MPG 3288 kb)

Movie 1: Twenty-nine days after Impella 5.0 insertion, transthoracic echocardiogram revealed slight aortic insufficiency in case 1 (MPG 3180 kb)

Movie 2: A defect between right coronary cusp and non-coronary cusp became evident on transesophageal echocardiogram when Impella was removed in case 1 (MPG 2876 kb)

Movie 3: Transesophageal echocardiogram detected moderate aortic insufficiency when Impella was removed in case 1 (MPG 3390 kb)

Movie 4: Transthoracic echocardiogram revealed trivial aortic insufficiency one day after the central aortic valve closure at durable left ventricular assist device implantation in case 1 (MPG 3278 kb)

Movie 5: Transthoracic echocardiogram showed no obvious regurgitation flow just after Impella 5.0 insertion in case 2 (MPG 4786 kb)

Movie 6: Transthoracic echocardiogram detected moderate aortic insufficiency when Impella was transiently removed in case 2 (MPG 5298 kb)

Movie 7: Transthoracic echocardiogram showed no obvious aortic insufficiency two days after the central aortic valve closure at durable left ventricular implantation in case 2 (MPG 3288 kb)

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Oishi, H., Kondo, T., Fujimoto, K. et al. Aortic insufficiency associated with Impella that required surgical intervention upon implantation of the durable left ventricular assist device. J Artif Organs (2020). https://doi.org/10.1007/s10047-020-01184-x

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Keywords

  • Impella
  • Aortic insufficiency
  • Cardiogenic shock
  • Left ventricular assist device