Interact CardioVasc Thorac Surg 2007;6:818-819. doi:10.1510/icvts.2007.159558
© 2007 European Association of Cardio-Thoracic Surgery
Case report - Assisted circulation |
Acute ventricular septal defect treated with an Impella recovery as a ‘bridge therapy’ to heart transplantation
Francesco Patanè*,
Edoardo Zingarelli,
Fabrizio Sansone and
Mauro Rinaldi
Department of Cardiac Surgery, San Giovanni Battista Hospital, C.so Bramante 88, 10126 Turin, Italy
Received 21 May 2007;
received in revised form 1 July 2007;
accepted 3 July 2007
*Corresponding author. Tel.: +39-11-6335510; fax: +39-11-6335509.
E-mail address: f_patane{at}hotmail.com (F. Patanè).
 |
Abstract
|
|---|
We present the case of a 59-year-old male, admitted to hospital for cardiogenic shock due to massive infero-lateral myocardial infarction. Angiography showed occlusion of the right coronary artery and widespread critical lesions of both the anterior descending and circumflex artery. Echocardiography showed inferior akinesia with a large posterior ventricular septal defect (VSD). The haemodynamic instability induced us to use a left ventricular assist device (L-VAD) like Impella for easiness of its percutaneous implantation and for its duration. We obtained the stabilisation of the patient and the improvement of the clinical conditions. The location of the ventricular septal defect (VSD), from one side, and the serious and widespread coronaropathy (not suitable for any kind of revascularisation), from the other side, led us to choose heart transplantation for this patient. Heart transplantation was performed on the 12th day after myocardial infarction without complication and the patient was discharged on the 35th postoperative day. In our opinion, when the position of the VSD is unseemly and there coexists a widespread coronaropathy not eligible for revascularisation, heart transplantation may represent an efficacious alternative. Moreover, the use of L-VAD, reducing interventricular shunt and ensuring an adequate cardiac output, allows to obtain clinical stabilisation before heart transplantation.
Key Words: Ventricular septal defect; Left ventricular assist device; Heart transplantation
|
1. Patient characteristics
|
|---|
We describe the case of a 59-year-old male admitted to hospital for cardiogenic shock with hypotension, oligoanuria and dyspnoea; angina appeared three days before. ECG showed an infero-lateral myocardial infarction. Echocardiography showed a large VSD just behind the posterior leaflet of the mitral valve and in connection with mitral annulus; mitral regurgitation was trivial and the right ventricle was seriously impaired with severe hypokinesia (TAPSE 12 mm); QP/QS was >2 and systolic pulmonary artery pressure (PAPs) was 85 mmHg. Angiography showed occlusion of the right coronary artery and a widespread coronaropathy of both the anterior descending and circumflex artery. The patient was reanimated because of cardiac arrest: the worsening of his condition forced us to use intra-aortic balloon pump (IABP) and L-VAD (Impella Recovery P7: 4 l/min flow) as a ‘bridge to heart transplantation’: its percutaneous implantation without sternotomy makes the procedure very easy with a low risk of infections and mechanical complication during heart transplantation; moreover, its duration is enough to assure the suitable donor's finding.
We obtained an improvement both in clinical conditions and biological parameters of the patient: there was a reduction of bilirubin, transaminase and creatinine (the patient needed a short period of dialysis) with a slow improvement of renal and hepatic function. Heart transplantation was performed on the 8th day after positioning L-VAD and the patient was discharged on the 35th postoperative day.
|
2. Surgery procedure and pathological characteristics
|
|---|
During angiography, we positioned an Impella Recovery (P7; flow 4 l/min) through the right femoral artery. During heart transplantation, after cardiectomy, we observed the large VSD (3 cmx4 cm) located just behind the postero-lateral papillary muscle in connection with the mitral annulus (Fig. 1): the risk of mitral regurgitation was too high and the surrounding tissue was still too delicate to allow an adequate suture.
View larger version (116K):
[in this window]
[in a new window]
|
Fig. 1. Macroscopic examination shows a large ventricular septal defect just behind the postero-lateral papillary muscle and in connection with the mitral annulus.
|
|
|
3. Discussion
|
|---|
The main determinant factor of early outcome following VSD is the appearance of acute heart failure, depending on the degree of interventricular shunt and the extension of ischaemic tissue [1, 2].
A quick VSD recognition allows to avoid clinical deterioration of the patient and choose the best strategy [3, 4]. The objectives of the use of Impella in case of VSD are: (Fig. 2) - Reduction of left ventricular systolic pressure (LVSP);
- Reduction of inter-ventricular shunt;
- Improvement of cardiac output (CO);
- Improvement of right ventricular function.
We observed a reduction of pulmonary artery pressure (PAP) and SVO2 with an improvement of CO, which showed a reduction of interventricular shunt. Echocardiography was not useful in measuring the entity of interventricular shunt because of the interferences of Impella with the echocardiographic feeler.
In our case, VSD is not suitable for standard surgical approach for these reasons: - Location of VSD, very close to postero-lateral papillary muscle, posterior leaflets of the mitral valve and in connection with the mitral annulus, without enough tissue to suture the patch preserving mitral valve function (Fig. 1).
- Coronaric anatomy: the widespread coronaropathy, the shortage of the run-off and the unfavourable anatomy of the vessels like ‘rosary crown’, determined the uselessness of surgical revascularisation;
- The age of the patient.
In conclusion, our experience confirms that the use of Impella is useful in the stabilisation of these patients; moreover, in patients with VSD not suitable to the surgical repair, cardiac transplant represents a valid alternative.
|
References
|
|---|
- Levy B, Perrin O, Thisse JY, Houppe JP, Villemot JP, Danchin N. Myocardial infarction caused by thrombosis of the common trunk of the left coronary artery without collateral circulation. Treatment by intra-aortic counterpulsation and subsequent heart transplantation. Arch Mal Coeur Vaiss Dec 1992; 85:1861–1863.[Medline]
- Tatou E, Gomez MC, Leneuf P, Eicher JC, Jazayeri S, Charve P, Girard C, Brenot R, David M. Cardiogenic shock complicating extensive infarction with ventricular septal defect. Circulatory assistance and heart transplantation. Arch Mal Coeur Vaiss Mar 2001; 94:236–240.[Medline]
- Baillot R, Pelletier C, Trivino-Marin J, Castonguay Y. Postinfarction ventricular septal defect: delayed closure with prolonged mechanical circulatory support. Ann Thorac Surg Feb 1983; 35:138–142.[Abstract]
- Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect — can we do better? Eur J Cardiothorac Surg Aug 2000; 18:194–201.[Abstract/Free Full Text]
|
|
Top
Abstract
1. Patient characteristics