Impella implantation in children: Bridge to where?

Abstract

Title: Impella implantation in children: Bridge to where? Anila B. Elliott MD, Bridget Pearce MD Introduction Mechanical circulatory support in children has largely relied on Extra Corporeal Membrane Oxygenation (ECMO) as a temporary bridge to destination therapy (DT). However, children on ECMO likely need mechanical ventilation, long-term sedation, and are at for risk bleeding and thrombotic complications. Pediatric patients now have the option for percutaneous MCS (p-MCS) devices that are much smaller, need less anticoagulation, and do not require ventilation or prolonged sedation. We present two adolescents who underwent p-MCS placement as a bridge to different destinations therapies.

Objectives: Upon completion of this activity, the learner should be able to: 1. Describe perioperative and anesthetic management of children for placement of p-MCS devices 2. Discuss alternative destination therapies after temporary p-MCS

Case report: Patient A is a 17-year-old female with dilated cardiomyopathy and severe biventricular dysfunction. Given potential improvement in cardiac function with goal directed medical therapy for reverse remodeling, support with a temporary p-MCS device, the Impella, was chosen as a bridge to recovery. Patient B was a 14-year-old male with a history of LMNA-associated dilated cardiomyopathy with severely depressed left ventricular function. Impella device implantation was chosen as a bridge to transplantation. Perioperative planning for both patients involved pediatric anesthesia, cardiac surgery, perfusion, and cardiology. The plan for the hybrid procedure was general anesthesia with invasive vascular access, defibrillator pad use, and inhaled nitric oxide for RV protection. Percutaneous Impella insertion into the LV was planned via axillary artery but given small size, preparation was made for sternotomy to access a larger artery if needed. A CPB circuit was primed, and groins were prepped in case of need for emergent cannulation for bypass. Anesthesia goals included maintaining cardiac output by avoiding negative inotropes, and cardiovascular support with vasoactive medication if needed. Goals were met with benzodiazepines, opioids, etomidate, rocuronium and ketamine as well as norepinephrine and milrinone infusions. Under fluoroscopic and TEE guidance, the Impella device was placed via axillary artery with use of a prosthetic hood graft. Both patients tolerated the procedure well and were extubated POD 1. Both were anticoagulated with bivalirudin. Patient A continued to have malignant arrhythmias and Impella suction events. For social reasons, she was not a transplant candidate and a month later underwent HeartMate 3 VAD placement (bridge to durable bridge). Patient B was stable on p-MCS and two weeks later received a heart transplant.

Conclusions: The Impella device is a viable alternative to ECMO as a bridge for pediatric patients but careful perioperative multidisciplinary planning is paramount to provide optimal care for these patients. There are many advantages to p-MCS compared to ECMO, including not requiring mechanical ventilation or prolonged sedation and less anticoagulation. The temporary device allows options for multiple destination therapies Including recovery, durable VAD or transplantation.

Reference: 1. Dimas, V.V., et al. Catheter Cardiovasc Interv 2017; 90(1): 124-129