Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to treat cardiogenic shock. However, a lack of left ventricle (LV) unloading and increased systemic afterload can cause pulmonary congestion. Impella (Abiomed, Danvers, MA, USA), a catheter-mounted micro-axial rotary pump, unloads the LV and provides hemodynamic support. However, Impella cannot support the right ventricle (RV), and RV dysfunction impedes weaning from VA-ECMO. A 50-year-old man with heart failure with reduced ejection fraction due to myocardial infarction developed moderate aortic stenosis and regurgitation, moderate mitral regurgitation, and tricuspid regurgitation. Aortic valve replacement, mitral valve replacement, and tricuspid valve replacement were performed. VA-ECMO with intra-aortic balloon pump (IABP) was initiated as he could not be weaned from cardiopulmonary bypass. The patient could not be weaned from IABP and VA-ECMO; therefore, Impella 5.0 was inserted instead of IABP on day 7. However, Impella 5.0 was ineffective due to RV dysfunction. Increased inhaled nitric oxide (iNO) dose lowered pulmonary vascular resistance, decreased RV afterload, and improved RV distension. He was weaned from VA-ECMO after increasing the flow from the Impella 5.0. Combining VA-ECMO with Impella and iNO improved hemodynamics in a patient with RV dysfunction, and Impella with iNO aided weaning from VA-ECMO.
Learning objective
Combining venoarterial extracorporeal membrane oxygenation (VA-ECMO) with Impella (Abiomed, Danvers, MA, USA) and inhaled nitric oxide (iNO) can improve hemodynamics in a patient with right ventricular dysfunction, and iNO may aid weaning from VA-ECMO.
Keywords: Impella, Nitric oxide, Venoarterial extracorporeal membrane oxygenation
Introduction
Cardiogenic shock after cardiovascular surgery is associated with a high mortality rate [1] and often requires mechanical support [2]. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) is one of the options for hemodynamic support, it can increase the left ventricular afterload. The Impella device (Abiomed, Danvers, MA, USA) has been used together with VA-ECMO as a left ventricle (LV) vent [3]. Inhaled nitric oxide (iNO) can selectively dilate the pulmonary vasculature and decrease pulmonary vascular resistance, resulting in a decrease in the right ventricular afterload [4]. However, the combined use of Impella and iNO following cardiac surgery has not been reported. In this study, we report the use of Impella and VA-ECMO to treat biventricular heart failure after cardiac surgery and the efficacy of iNO with Impella while weaning from VA-ECMO to support the right ventricle (RV).
Case report
A 50-year-old man who underwent percutaneous coronary intervention for acute anteroseptal myocardial infarction was admitted to a regional hospital with a 1-month history of dyspnea on exertion. Echocardiography revealed moderate aortic stenosis and regurgitation with calcification, functional moderate mitral regurgitation, and secondary tricuspid regurgitation. The left ventricular ejection fraction (LVEF) had decreased to 22 %. He had been treated with furosemide and dobutamine and needed continuous intravenous inotropic support. The patient was transferred to our hospital for cardiac surgery. Aortic valve replacement, mitral valve replacement, and tricuspid valve replacement were performed. The cause of aortic stenosis was degenerative changes with calcification, and secondary changes were observed in mitral and tricuspid valves. VA-ECMO was initiated through the right femoral artery and vein and intra-aortic balloon pump (IABP) through the left femoral artery due to the inability to wean from cardiopulmonary bypass. The flow from VA-ECMO was set at 2.1 L per minute, and the patient was admitted to the intensive care unit under 5 γ of dopamine, 5 γ of dobutamine, and 0.08 γ of norepinephrine. NO administration (20 ppm) was initiated. On day 2, he could be weaned from IABP; however, the hemodynamics remained unstable. Therefore, the IABP was reintroduced on day 3. On day 7, the patient could not be weaned from IABP and VA-ECMO; therefore, we decided to implant Impella 5.0 instead of IABP for weaning the patient from VA-ECMO.
After inserting Impella 5.0, the patient suffered from biventricular dysfunction. Lowering the VA-ECMO flow decreased systemic blood pressure and increased pulmonary artery pressure. Furthermore, increasing the Impella flow led to the LV collapse, and the flow from the Impella became unstable. However, increasing iNO dose resulted in a decrease in pulmonary vascular resistance, the RV afterload, and improvement of the distension of the RV (Fig. 1). Upon increasing the iNO dose, the mean pulmonary artery pressure decreased; however, the mean aortic pressure was stable (Fig. 1). iNO improved the blood circulation from the right to the left heart system, which increased the Impella preload and stabilized its flow. Consequently, the flow from the Impella increased, and the patient was successfully weaned from VA-ECMO on day 13.
Fig. 1.
Hemodynamic parameters and images of echocardiogram with concomitant use of Impella and venoarterial extracorporeal membrane oxygenation (VA-ECMO) with inhaled nitric oxide (iNO) on postoperative day 8.
AoP, aortic pressure; CVP, central venous pressure; PAP, pulmonary artery pressure.
As the LV function recovered, we removed Impella 5.0 and inserted Impella 2.5 through the right axillary artery on day 31 since the axillary approach allows early mobilization. On day 46, Impella 2.5 support was terminated as the left heart function improved further. The patient was started on sildenafil and was weaned off iNO. His general condition improved, and he was discharged on day 162. Echocardiogram performed 7 months after surgery revealed an improved LVEF of 32 %.
Discussion
Approximately 1–3 % of patients require mechanical circulation support after cardiac surgery [2]. Although VA-ECMO is used widely, its use has been associated with myocardial damage and pulmonary congestion due to increased systemic afterload. Current management of LV unloading for patients on VA-ECMO involves IABP or the surgical insertion of the left atrium (LA) or LV vent [5]. However, the effectiveness of IABP remains unclear [6]. Moreover, the surgical insertion of an LA or LV vent is invasive and involves the risk of complications.
Impella has been reportedly used against cardiogenic shock after cardiac surgery, showing good outcomes [7]. Impella offers a higher degree of hemodynamic support than IABP and is less invasive than the surgically inserted LA or LV vent. Moreover, using Impella as an LV vent combined with VA-ECMO improved the survival rate in patients with cardiogenic shock [3]. Recently, the concomitant use of VA-ECMO and Impella after cardiac surgery has also been reported [8].
VA-ECMO is usually withdrawn first when combined with Impella for heart recovery. However, in cases of right heart failure, the RV cannot circulate the blood from the right to the left heart. Therefore, Impella cannot have adequate preload, resulting in a leftward shift of the interventricular septum and unsteady flow from Impella. The issue of right heart function is reportedly a problem in patients with a left ventricular assist device (LVAD) implant [9]. iNO decreases pulmonary vascular resistance, lowers pulmonary arterial pressure, and increases the maximal achievable LVAD speed, avoiding the need for an RV assist device [4]. On the other hand, a previous report showed there is a risk of pulmonary congestion resulting from increased LV preload in patients with low cardiac function [10]. Impella may reduce the disadvantages of iNO because of its LV unloading effect. Therefore, Impella support during iNO use might be important. In the current case, it was difficult to wean from VA-ECMO due to right heart failure. The RV volume and pulmonary artery pressure fluctuated depending on the dose of iNO, as noted on the transesophageal echocardiography and right heart catheter. Therefore, we increased the iNO dose, and the flow from the Impella was stabilized. Subsequently, the patient was successfully weaned from VA-ECMO. The previously reported benefits of iNO combined with LVAD were achievable with Impella and iNO.
In conclusion, the combination of VA-ECMO and Impella is a valuable option for managing postoperative cardiogenic shock. Inhalation of nitric oxide may aid weaning from VA-ECMO in cases of biventricular heart failure.
Declaration of competing interest
The authors declare that there is no conflict of interest.
Acknowledgments
Acknowledgments
None.
Ethics approval and informed consent
The patient provided informed consent to receive the treatment provided to them. Informed consent to publish was obtained from the patient presented in this article.
Availability of data and materials
Not applicable.
Funding
None.
Meeting presentation
The 254th Regional Meeting of the Japanese Circulation Society in the Kanto District at Station Conference, Tokyo, dated 7th Dec 2019.
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