This case is supported by Abiomed. 

Patient presentation

A 77-year-old obese female with diabetes mellitus, hypertension, and dyslipidemia initially presented in the catheterization laboratory at Ochsner Heart and Vascular Institute with signs of acute systolic heart failure. On angiography, the left ventricular ejection fraction (EF) was 25%, down from 60% as measured one year prior to admission. Diagnostic angiography identified three-vessel coronary artery disease. Cardiac enzymes were positive including a peak troponin of 15. Four hours post angiography, the patient experienced asystolic arrest and was resuscitated by advanced cardiac life support.

A cardiac surgery consult determined that the patient’s low EF, recent history of cardiac arrest, and other co-morbidities made her an unacceptable candidate for surgical revascularization. Days after the patient was stabilized, the decision was made to proceed with a percutaneous coronary intervention (PCI) supported with the Impella 2.5 Circulatory Support System (Abiomed).

Procedure description

Thirteen days following her asystolic arrest, the stabilized patient returned to the catheterization laboratory for an Impella-supported high-risk PCI. The Impella 2.5 device was inserted percutaneously via the left femoral artery and support was started on Performance Level 7 (P-7), with axial pump output flow of 2.0-2.1 liters per minute.

Baseline angiography identified a high-grade lesion within the proximal LAD (Figure 1) that was predilated and subsequently stented with an excellent angiographic result (Figure 2).

In addition, the right coronary artery (RCA) was severely diseased in both proximal and mid portions (Figure 3). Following placement of a guide wire in the RCA, the patient developed complete heart block. The heart block lasted for longer than two minutes, during 

whichtime Impella support was increased to Performance Level 9 with forward flows of 2.3 liters per minute.

The patient remained conscious during the episode of complete heart block. Although she had no pulsatile flow, her mean arterial blood pressure was maintained at 50 mm Hg by the Impella 2.5 device. With the return of sinus rhythm, atropine was administered and her heart rate and blood pressure quickly normalized. The proximal and mid RCA lesions were each subsequently stented with a drug-eluting stent (DES) (Figure 4) without arrhythmia onset or sudden drop in blood pressure during the PCI.

Case outcome

After completion of the PCI procedures, the patient was weaned from Impella circulatory support, the device was removed, and the access site closed with a suture-based closure device. The patient’s clinical condition improved significantly over the next 24 hours and she was subsequently discharged.

Device description

The Impella 2.5 microaxial blood pump is percutaneously placed in the left ventricle to provide up to 2.5 liters per minute of non-pulsatile blood flow into the aorta. The pump configuration is unique in that it is inserted through a 13 French (Fr) sheath placed in the femoral artery with a 9Fr steering catheter passed across the aortic valve to position the inflow port within the left ventricle, while the outflow port and axial flow pump are positioned within the ascending aorta (Figure 5). The catheter is attached to the Automated Impella Controller (Figure 6), which provides continuous output and performance data on a display panel.

Discussion

This patient with significant coronary artery disease and confounding cardiac dysfunction underwent a successful high-risk coronary intervention of the LAD coronary artery and RCA with placement of DES at each lesion. The entire procedure was performed with the support of the Impella 2.5 Circulatory Support System. 

Maintenance of near-normal systemic blood pressure during the three PCI procedures kept the patient free from hemodynamic compromise and was especially important during the two-minute interval of cardiac standstill.

This case demonstrates the feasibly and ease of use of the Impella 2.5 device during high-risk complex percutaneous coronary interventions. The most striking aspect of this case was the support afforded the patient at the time of her heart block and resulting asystole. Despite the asystolic episode, she remained completely lucid and appeared to suffer no deleterious effect from this event. While on Impella, the patient remained stable and never exhibited any sign of distress. On restoration of cardiac rhythm, the revascularization procedures were completed with excellent angiographic and physiologic outcomes. Without the vital support provided by the Impella 2.5 device, the procedural outcome might have been appreciably worse.