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How I Do It: Perioperative Use of Micro-Axial Pumps in High Risk Coronary Artery Bypass Grafting: The Early Johns
Salman Zaheer1, Mohammad Aref2, Oldrich Virag3
1Division of Cardiac Surgery, Penn State Milton S. Hershey Medical Center, 200 Campus Dr., Hershey, PA 17033, USA.
Insights
Planned Impella use in high-risk cardiac surgery can proactively mitigate postcardiotomy shock (PCS) in patients with left ventricular dysfunction. Early experience shows this approach is feasible and beneficial, with no postoperative mortality in a small cohort.
Area of Science:
- Cardiovascular Surgery
- Mechanical Circulatory Support
- Critical Care Medicine
Background:
- Patients with left ventricular dysfunction undergoing cardiac surgery are at high risk for perioperative complications like postcardiotomy shock (PCS).
- Current management with inotropes and vasopressors may worsen end-organ dysfunction, necessitating alternative strategies.
- Mechanical circulatory support (MCS) offers a proactive option for high-risk surgical patients.
Purpose of the Study:
- To present early experience with planned Impella utilization in high-risk cardiac surgery at Johns Hopkins.
- To detail a novel risk stratification methodology for identifying optimal candidates for perioperative MCS.
- To describe patient selection, surgical technique, and perioperative management protocols.
Main Methods:
- Development of a risk stratification scoring system based on surgical intent, myocardial function, postoperative course, and exit strategy.
- Intraoperative central placement of the Impella 5.5 device.
- Retrospective review of 11 consecutive patients with ejection fraction <30% undergoing Impella-assisted cardiac surgery.
Main Results:
- Favorable outcomes observed in the initial cohort of 11 high-risk patients.
- No postoperative mortality reported.
- Successful two-year follow-up data available for the cohort.
Conclusions:
- Planned Impella use in high-risk cardiac surgery appears feasible and beneficial.
- The developed risk stratification tool aids in selecting appropriate candidates for perioperative MCS.
- Further research is warranted to validate findings, assess long-term efficacy, and evaluate cost-effectiveness.
Abstract:
Patients with left ventricular dysfunction undergoing cardiac surgery face a heightened risk of perioperative complications, including postcardiotomy shock (PCS). Conventional management with inotropes and vasopressors can exacerbate end-organ dysfunction, underscoring the need for alternative strategies. The planned use of mechanical circulatory support (MCS) devices, such as the Impella, offers a proactive approach to mitigating PCS in high-risk patients. This study presents our early experience at Johns Hopkins with planned Impella utilization in high-risk cardiac surgery. We detail our risk stratification methodology, patient selection criteria, and perioperative management strategies. Our proposed risk stratification scoring system incorporates surgical intent, preoperative myocardial function, anticipated postoperative course, and exit strategy to identify optimal candidates for perioperative MCS. We describe the intraoperative central placement technique for the Impella 5.5, perioperative management protocols-including anticoagulation strategies and weaning protocols-and postoperative device extraction. A retrospective review of our first 11 consecutive patients with severely reduced left ventricular ejection fraction (<30%) who underwent Impella-assisted cardiac surgery demonstrated favorable outcomes, with no postoperative mortality and a two-year follow-up. Our findings suggest that planned Impella use in high-risk cardiac surgery is both feasible and beneficial. However, further studies are necessary to validate these results, assess long-term outcomes, and evaluate cost-effectiveness.
