Case Review Video: Management of Myocarditis Patient

August 20, 2019

Impella 5.0® Heart Pump Support Until Transplant

Dr. Roberta Bogaev and Dr. Shashank Desai present a case study in which Impella 5.0® support helped a patient with myocarditis achieve a successful heart transplant. The collaborative relationship between Dr. Bogaev from Bon Secours Health Systems, and Dr. Desai from Inova Fairfax Hospital, figures prominently in this case. Dr. Bogaev works at a destination therapy center and frequently discusses cases with Dr. Desai and Inova, her transplant partners.

The case Dr. Bogaev presents is a 65-year-old female, previously very fit, who developed a viral illness that progressed to heart failure and myocarditis. Dr. Bogaev describes her initial evaluation and determination that the patient was in cardiogenic shock despite inotropic support. She sought a surgical consultation for Impella 5.0 hoping for heart recovery since the patient had been very physically fit before the onset of the viral illness. Impella 5.0 was determined to be the patient’s best option.

Realizing that the patient may ultimately require a heart transplant, Dr. Bogaev shared the case with Dr. Desai at Inova, and he presented the case to his transplant board. Dr. Desai emphasizes the seamless journey for this patient as a result of his collaboration with Dr. Bogaev and her institution. He notes that it is important in a myocarditis case such as this to discuss how to escalate patients from one institution to another with options for temporary support, permanent support, or transplantation. Being able to consider all these options, he explains, impacts every treatment decision along the way in determining what's best for the patient.

Dr. Desai emphasizes that myocarditis needs acute and aggressive support. "Oftentimes its ECMO," he states. "But ECMO to what?" While there was evidence of RV dysfunction in this patient, his experience was that Impella 5.0 support of the LV alone often suffices. He explains that it’s worth the unloading, as opposed to the loading, in myocarditis, to help stabilize patients. Dr. Bogaev discusses how implanting Impella 5.0 in this patient helped the patient ambulate and remain active as she waited for either transplant or recovery.

Dr. Desai discusses hemodynamic markers and the importance of preserving organ function in order to have a successful transplant. Dr. Bogaev explains that they were able to treat this patient relatively early in the shock phase and were able to support her with Impella 5.0 before she developed renal dysfunction. Although support ultimately could not maintain adequate perfusion in this case, it was enough to keep the patient eligible for transplant and enable safe transport to the transplant center. "A little bit of time often helps all of those organs get better," notes Dr. Desai.

Dr. Desai explains how the patient continued to improve with Impella 5.0 support after transfer and did not require inotropic support as many cases of myocarditis do. Dr. Desai describes how his collaboration with Dr. Bogaev enabled the case to arrive at Inova on Day 0, and through improvements with the Impella 5.0 in place, be ready for transplant and be actively listed by Day 4. By Day 13 a heart was found and implanted, and the patient was discharged Day 24. At time of this interview, the patient was 6 months out from transplant.

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