Biventricular Support in Procedural Cardiogenic Shock

August 23, 2019

Use of Impella RP and Impella 2.5 for MitraClip Procedure

Dr. Kamran Muhammad discusses a challenging case illustrating the decision to use Impella RP® with Impella 2.5® to provide biventricular support. Dr. Muhammad is a subspecialist in interventional cardiology at Oklahoma Heart Institute in Tulsa, Oklahoma.

The patient was an 81-year-old female presenting to the hospital over several months with acute on chronic systolic and diastolic heart failure. The patient had multiple comorbidities, severe mixed cardiomyopathy with LVEF 15%, severe right ventricular myopathy, moderately severe tricuspid regurgitation, and severe mitral regurgitation.

Dr. Muhammad describes the heart team’s evaluation of this patient and the decision to approach the severe mitral regurgitation with a transcatheter method using a MitraClip™. Shortly after induction of general anesthesia, while the MitraClip was still standing open in the right atrium, the patient developed severe hypotension and shock. An Impella 2.5 was inserted, but her shock appeared to worsen. Transesophageal echo seemed to show a growing hematoma, which turned out to be the echo pulling a ballooning right atrium and ventricle into view with a significantly decompensated left ventricle. The team turned down the support level on the Impella 2.5 to P3. “Immediately her BP came up,” Dr. Muhammad explains, “and the big right side of heart on transesophageal echo receded in front of our eyes.” Thus, they diagnosed severe biventricular failure worsened by left ventricular support alone and recognized that right side support was needed.

The team quickly implanted an Impella RP on the right side, however, as Dr. Muhammad notes, “This was a little bit interesting because, as you know, MitraClip is done exclusively from femoral venous access as is Impella RP.” He explains how the team obtained dual large bore access in the right femoral vein and within moments of positioning and activating the Impella RP the patient’s shock appeared to improve and resolve. The patient remained stable while the team finished deploying the MitraClip.

The key messages Dr. Muhammad shares from this case are to recognized right ventricular mediated shock and find the appropriate balance between right side support and left side support. He also discusses access and closure issues with both MitraClip and Impella RP in the right femoral vein. For access, he advises sticking lower for Impella RP for better control if there is a complication. For closure, he explains how his team used a robust Figure of 8 since Impella RP insertion was done emergently.

Dr. Muhammad reports that this patient did well and was discharged home at Day 5 post MitraClip. LVEF improved from 15% to 30-35% at 6-month follow up and patient was doing well more than 12 months out.

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