Successful Use of Impella RP to Treat Acute Right Heart Failure in Massive Pulmonary Embolism

Purpose: Impella RP was approved by the Food and Drug Administration (FDA) in 2017 for temporary emergency support of right ventricular failure for up to 14 days. Recently, it has been in headlines after the FDA questioned its safety profile based on postapproval study data. There are only handful cases reported in the literature in which Impella RP was successfully used along with EKOS in management of massive pulmonary embolism. By reporting this case, we acknowledge the scarcity of data to support the Impella RP use for this indication.

Materials and Methods: Case details were gathered from electronic medical records. Detailed review of literature was performed using PubMed.

Results: A 70-year-old man presented with sudden onset difficulty breathing with associated chest pressure. He was hemodynamically unstable, with being hypotensive (blood pressure, 92/30 mm Hg), tachycardia (heart rate, 110–120 beats/min), tachypneic (respiratory rate, 28–30/min), and hypoxic. His initial troponin was unremarkable, and NTpro-BNP (N-terminal pro B-type natriuretic peptide) was elevated. An emergent chest and pulmonary computed tomography revealed massive saddle pulmonary embolism (PE). Echocardiogram showed akinetic mid free wall and hyperkinetic apex of right ventricle. A decision was made to proceed with ultrasound-assisted catheter-directed thrombolysis using EKOS. After the initiation to recombinant tissue plasminogen activator infusion, the patient remained hemodynamically unstable. The patient received adequate intravenous (IV) fluid boluses and was started on IV epinephrine drip, but he failed to respond. Because of persistent hemodynamic instability and elevated pressure in the right heart, it was decided to support the right ventricle with Impella RP. After Impella RP placement, there was a significant improvement in the patient’s blood pressure and symptoms, and we was able to complete EKOS. He was discharged home on the third day of hospitalization.

Conclusions: Obstructive shock and acute right ventricular (RV) failure caused by massive PE have poor prognosis and are associated with a high mortality rate. It is important to establish demarcation between RV strain and RV failure. RV strain can be predicted from electrocardiography, echocardiography, computed tomography angiography, and biomarkers such as troponin and NTpro-BNP. Acute RV failure should be considered in patients with high clot burden when more than 50% of the pulmonary artery tree is occluded by thrombus and who persist to have hypotension and hemodynamic instability even after IV fluids and pressor support. Our case highlights the favorable clinical outcomes with the use of Impella RP and EKOS in this situation, avoiding the need for extracorporeal membrane oxygenation.