Crossing Boundaries: Utilizing Left-sided Impella for Right Ventricular Mechanical Support and Intraoperative Transesophageal Echocardiogram Considerations

Objective: Right ventricular failure is a leading cause of mortality among patients with various etiologies of cardiogenic shock. This case series outlines an innovative approach to directly unloading the right ventricle with the Impella LD or 5.5 without crossing the tricuspid valve in cases requiring tricuspid valve repair or replacement.

Design: Retrospective single-center review.

Setting: Single tertiary care university hospital.

Participants: Patients who underwent Impella LD or 5.5 insertions for right ventricular support.

Interventions: Impella LD or 5.5 inserted directly into the right ventricle via the pulmonary artery.

Measurements and main results: Patients' baseline, intraoperative, and immediate postoperative clinical and echocardiographic data were obtained. Of the five consecutive patients with severe preoperative right ventricular failure who underwent surgical tricuspid valve procedures and Impella placement, three of the patients underwent concomitant left heart procedures. The Impella was preemptively inserted before separation from cardiopulmonary bypass in all patients. Four patients were extubated within the first 24 hours and ambulated with the Impella by postoperative day (POD) 3. By POD 10, four patients had sufficient right ventricular recovery to allow for Impella LD explant. One patient died due to septic shock with the right ventricular assist device still in place. One patient was transitioned to comfort measures 29 days after explant of the Impella device.

Conclusions: Left-sided Impella can be used to support the right ventricle in patients who have undergone surgical tricuspid valve procedures. It provides direct right ventricular unloading, does not cross a newly replaced or repaired tricuspid valve, and allows early ambulation.