Impella Support for Surgical Ventricular Septal Defect Repair

• Published in: ASAIO journal (1992) Vol. 69; no. 6; p. e278
• Main Authors: Ruiz Duque, Ernesto, Hohenwarter, Marian R, Isom, Nicholas R, Singhal, Arun K
• Format: Journal Article
• Language: English
• Published: United States 01.06.2023
• Subjects: Echocardiography; Heart Septal Defects, Ventricular - surgery; Heart Ventricles; Humans; Myocardium; Shock, Cardiogenic - etiology; Shock, Cardiogenic - surgery
• ISSN: 1538-943X
• DOI: 10.1097/mat.0000000000001873

Acute postinfarct ventricular septal defect (VSD) is associated with high mortality due to a combination of cardiogenic shock and a complex repair in recently infarcted fragile myocardium. 1 Although the Impella heart pump is established as support for cardiogenic shock, it is relatively contraindicated in postinfarct VSD because of potential right-to-left shunt or stroke due to VSD tissue-related embolus. On autopsy, early repair is technically difficult due to tissue friability and as a result, 38% of surgically repaired patients have evidence of recurrent interventricular septal rupture. 2 Delayed surgical repair (>7 days) is associated with superior survival-54% after 7 days versus 18% prior-but hemodynamic instability may prevent delay. 3 Case reports have shown successful early left ventricular unloading with Impella patients with acute postinfarct VSD before surgical repair. 4,5 We discuss our algorithm for pre-repair Impella support in which we stratify pre-repair support based on the Qp/Qs ratio. For VSD with Qp/Qs >2.5, we use a preoperative Impella heart pump and have not demonstrated reversal in the left-to-right shunt on echocardiography and/or stroke. Our findings are consistent with theoretical models of unloading as demonstrated by shifts in pressure-volume loops. 6.