Transaortic Impella LD Implantation

The patient was a 70-year-old woman who presented with hypertensive, peripheral vascular disease, three vessels disease, and NSTEMI (ISR). She had ongoing chest pain despite maximal medical treatment, NYHA III, EF 455, mild MR. Cardiac Enzymes; CK 21,1, CK-MB 2,74, Trop. 2071 (increasing). She underwent emergency on-pump CABG (LIMA-LAD, SVG-OM “T-graft on LIMA”). RCA showed max 50% stenosis with FFR 0,91.

Aortic cross clamp time 36 minutes, difficult weaning from cardiopulmonary bypass because of distended left ventricle with refractory hemodynamically significant ventricular tachycardia. Because of severe peripheral vascular disease, implantation of IABP was not possible. Surgical team decided to insert transaortic Impella LD to unload the left ventricle, support systemic circulation, and subsequently abrupt the refractory arrhythmia.

The aim of this video is to demonstrate the surgical technique of transaortic Impella insertion.

Surgical Technique:

- Sidebiting aortic clamp
- Aortotomy
- 10 mm Hemashield Dacron graft
- End to side anastomosis
- Under TOE guidance, direct insertion of Impella LD through the aortic valve
- Impella inlet should be 3.5 cm below the aortic valve.
- There are different options to tunnel and exit the catheter of Impella LD.
- Right second intercostal space (which is done in this patient)
- Suprasternal notch
- Lower sternal wound (Xiphoid area)
- These options allow the early mobility and recovery of the patient.
- Successful weaning from cardiopulmonary bypass and reducing the inotropic support
- On the fifth postoperative day, weaning and removal of the Impella LD

Conclusion
Transaortic impella LD insertion is safe and effective and technically easy to implant in postcardiotomy patients with cardiogenic shock, when it is implanted at a proper time before cardiac reserve is exhausted. Implantation is guided by transesophageal echocardiography without radiation exposure or call for interventional cardiologist help.

References

1. Meyns B, Dens J, Sergeant P, Herijgers P, Daenen W, Flameng W. Initial experiences with the Impella device in patients with cardiogenic shock - Impella support for cardiogenic shock. Thorac Cardiovasc Surg. 2003 Dec;51(6):312-317.
2. Siegenthaler MP, Brehm K, Strecker T, Hanke T, Nötzold A, Olschewski M, et al. The Impella Recover microaxial left ventricular assist device reduces mortality for postcardiotomy failure: a three-center experience. J Thorac Cardiovasc Surg. 2004 Mar;127(3):812-822.

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