Novel strategy for postcardiotomy support in a patient with adult congenital heart disease.

Central MessageUnique case where preoperative planning with 3D printing of complex intracardiac anatomy facilitated accurate trans-right axillary placement of a single-ventricle Impella device (Abiomed Inc) for postcardiotomy support. Unique case where preoperative planning with 3D printing of complex intracardiac anatomy facilitated accurate trans-right axillary placement of a single-ventricle Impella device (Abiomed Inc) for postcardiotomy support. Since its introduction into clinical practice, the Impella 5.5 device (Abiomed Inc) has been used for cardiogenic shock in acquired heart disease as a bridge to recovery, definitive left ventricular assist device (LVAD) placement, or to transplantation.1Dimas V.V. Morray B.H. Kim D.W. Almond C.S. Shahanavaz S. Sebastian C.T. et al.A multicenter study of the Impella device for mechanical support of the systemic circulation in pediatric and adolescent patients.Catheter Cardiovasc Interv. 2017; 90: 124-129Crossref PubMed Scopus (35) Google Scholar,2Tume S.C. Fuentes-Baldemar A.A. Anders M. Spinner J.A. Tunuguntla H. Imamura M. et al.Temporary ventricular assist device support with a catheter-based axial pump: changing the paradigm at a pediatric heart center.J Thorac Cardiovasc Surg. December 24, 2022; ([Epub ahead of print]. https://doi.org/10.1016/j.jtcvs.2022.11.039)Abstract Full Text Full Text PDF Scopus (1) Google Scholar However, its use for postcardiotomy support in adult patients with complex congenital heart disease (ACHD) undergoing reoperative cardiac surgery, has yet to be described. We report such a case requiring special planning to facilitate satisfactory placement of an Impella 5.5 device. Institutional review board approval (00,017,861) was obtained June 11, 2021, for the study protocol and publication of data. The patient provided informed written consent for the publication of the study data. A 26-year-old man with complex congenital heart disease (tricuspid atresia, malposed great vessels, and ventricular septal defect) palliated with a modified Damus-Kaye-Stansel operation3McElhinney D.B. Reddy V.M. Silverman N.H. Hanley F.L. Modified Damus-Kaye-Stansel procedure for single ventricle, subaortic stenosis, and arch obstruction in neonates and infants: midterm results and techniques for avoiding circulatory arrest.J Thorac Cardiovasc Surg. 1997; 114 (discussion 725-6): 718-725Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar and subsequent fenestrated lateral tunnel Fontan operation presented with severe pulmonary valve regurgitation (systemic semilunar valve) and severely reduced systemic LV function (ejection fraction, 30%). For his severe semilunar valve regurgitation, he underwent a third-time sternotomy with cardiopulmonary bypass (CPB) by central aortic cannulation and femoral venous cannulation. Following clamping of the ascending aorta, Del-Nido cardioplegia (1.25 L) was administered directly into the coronary ostia following aortotomy. A 21-mm bioprosthetic valve (Inspiris; Edwards-Lifesciences) was inserted in the intra-annular position using 2–0 Ethibond sutures. Following standard closure of the aortotomy, the patient was weaned off CPB with small doses of inotropes and Impella 5.5 device support. The Impella device was removed after 4 days and the patient was discharged home on the ninth postoperative day. The technical skillset required for Impella 5.5 device insertion merits special attention in complex intracardiac anatomy such as in this case. Of first consideration was assessment of the patient's vascular anatomy, which in this case consisted of preoperative computed tomography scanning, confirming the presence of a patent right axillary artery measuring 7 mm in diameter, and therefore of adequate size to facilitate Impella 5.5 device placement. To facilitate planning of Impella 5.5 device placement in complex anatomy, in particular to determine the intracardiac path of the device, we performed 3-dimensional [3D] printing of a cardiac model based on radiological imaging (Figure 1). This 3D model allowed presurgical planning for advancement of the Impella 5.5 device to traverse the right axillary and brachiocephalic arteries, the ascending aorta, the native aortic valve, the rudimentary right ventricle, bulbuventricular foramen, and its final placement in the center of the dilated LV cavity for an Impella length 5.5 cm (Figure 2). This was reproduced intraoperatively by anastomosing a beveled 8-mm Gelweave graft (Terumo Medical Corporation) to the right axillary artery exposed by a lateral infraclavicular incision and division of the pectoralis major and minor muscles, then advancing an AL-1 catheter (Terumo Medical Corporation) backloaded with a 0.035 J-Wire (Terumo Medical Corporation) under fluoroscopic guidance, into the LV cavity, and then changeover of these with an 0.018 Impella wire. Due to the direct approach required for accurate device placement, the initial guidewire was directed through the native pulmonary valve. This guidewire, at the time of aortotomy, was flipped through the native aortic valve and rudimentary right ventricle and Bulbuventricular foramen into the LV cavity. Following valve replacement and closure of aortotomy, the aortic clamp was removed. Under fluoroscopic guidance, the Impella 5.5 device was advanced over the 0.018-inch guidewire, and positioned appropriately in the LV as described above in our 3D model. Commencement of Impella 5.5 device support at 4.5 L/minute enabled successful weaning from CPB with epinephrine 0.05 μg/kg/minute.Figure 2Model of Impella 5.5 device (Abiomed Inc) across the native aortic valve and the ventricular septal defect.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Many patients with ACHD present requiring cardiac surgery, including valve replacements, in the face of severe systemic ventricular dysfunction and with history of multiple prior sternotomies. Although transplantation remains a good option for these patients, the paucity of suitable organs and the relative longevity of the patients vis-à-vis their cardiac allografts behooves contemplation of conventional cardiac surgery with mechanical circulatory support. Postcardiotomy extracorporeal membrane oxygenation support is a strategy to facilitate high-risk cardiac surgery, thereby preventing high inotropic support and multiorgan dysfunction associated with these, with reasonable results.4Mahesh B. Williams L. Punjabi P.P. Katsaridis S. Novel strategy for improved outcomes of extra-corporeal membrane oxygenation as a treatment for refractory post cardiotomy cardiogenic shock in the current era: a refreshing new perspective.Perfusion. 2022; 37: 825-834Crossref PubMed Scopus (1) Google Scholar Although the Impella 5.5 device has been described as a valuable strategy for bridging cardiogenic shock before implantation of LVAD or transplantation, to our knowledge, Impella 5.5 device support has not routinely been utilized for postcardiotomy support in ACHD, and here we show success of this approach in a patient with complex congenital heart disease. In this case, use of 3D printing facilitated accurate intracardiac placement of the Impella 5.5 device. Given the complex intracardiac anatomical constraints described here, we adopted this approach to prevent placement of the device through the wrong valve, and its consequent malpositioning against the interventricular septum or the lateral LV wall. Misplacement of the device in complex anatomy such as is reported here could result in flow limitation and hemolysis. Our report describes a unique case where careful preoperative planning with 3D printing of complex intracardiac anatomy facilitated accurate trans-right axillary placement of single-ventricle Impella 5.5 device for postcardiotomy support in complex ACHD.