Left ventricular perforation by Impella 5.5 during surgery for postinfarction ventricular septal rupture

The perioperative use of the Impella 5.5 has been increasing recently; however, the left ventricular perforation by this device during surgery has not been reported to date.

Postinfarction ventricular septal rupture in a 75-year-old man was successfully repaired with support of a single Impella 5.5 device used for consecutive 28 days perioperatively. The patient underwent surgery after 16 days of Impella support. During surgery, the Impella was left in place expecting its use for left ventricular unloading after the operation. After aortic cross-clamp, when the apex was carefully lifted, the tip of the Impella almost protruded from the posterior wall, and could be seen through the epicardium. The aorta was unclamped briefly, the Impella was pulled out several centimeters, and the aorta was cross-clamped again. The ventricular septal rupture was repaired by the double-layer patch technique via the right ventricle. Immediately before the chest closure, the free wall of the LV ruptured and blood rapidly flowed out. It was where the Impella almost protruded during cardiac arrest, and was repaired with a pledgeted monofilament mattress suture.

A single device can be used throughout perioperative periods; however, if used during surgery, possible risk of left ventricular perforation should be well recognized since the device has no soft pigtail part at its end, and its stiff tip can directly contact the decompressed, flaccid ventricular wall during cardiac arrest.