Delayed surgical repair via right ventricular approach with Impella and extracorporeal life support in post-myocardial infarction ventricular septal defect: A case report

TL;DR

A patient with a heart defect after a heart attack was successfully treated with delayed surgery using Impella and VA-ECMO to maintain stability.

Contribution

Demonstrates successful use of VA-ECMO in conjunction with Impella to delay high-risk surgery for post-myocardial infarction ventricular septal defect.

Findings

Impella alone was insufficient to manage right heart failure in a PIVSD patient.

VA-ECMO provided additional support, allowing delayed surgical repair without adverse events.

Successful delayed surgery was performed after one week of hemodynamic stabilization.

Abstract

Post-myocardial infarction ventricular septal defect (PIVSD) is a life-threatening mechanical complication of acute myocardial infarction (AMI). Delayed elective surgical repair can be considered in patients who respond well to aggressive heart failure therapy. Impella has been reported as a bridge to allow the deferment of surgery for PIVSD.

This report describes our case of a 62-year-old male with PIVSD and cardiogenic shock. Impella was placed to ensure hemodynamic stability. Subsequently, right heart failure was suspected to be caused by insufficient circulatory support from Impella alone. Emergency surgery was considered, but it was high risk and only a few days had passed since the onset. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted to treat right heart failure and delay surgical repair as long as possible. Six days after Impella implantation, the patient underwent a successful surgical repair via the right ventricle without associated adverse events.

Impella support can be insufficient for critically ill patients such as those with a larger ventricular septal defect and involvement of right ventricular function. VA-ECMO was implanted to support circulation, reduce the preload in the right ventricle, and avoid shunt inversion induced by increasing Impella flow. The patient was able to undergo a successful delayed repair with VA-ECMO at least one week after the onset of the AMI with hemodynamic stability and no associated adverse events.

Additional VA-ECMO could help patients who fail to bridge to surgery with Impella to avoid emergency surgery, leading to successful delayed surgical repair.

•Impella was inserted on a patient with PIVSD as a bridge-to-surgery.•RV failure developed even with Impella support.•Emergency surgery was considered, but it was high risk.•VA-ECMO was implanted to treat RV failure and delay repair surgery.•PIVSD was successfully repaired with surgery after acute heart failure was treated.

Impella was inserted on a patient with PIVSD as a bridge-to-surgery.

RV failure developed even with Impella support.

Emergency surgery was considered, but it was high risk.

VA-ECMO was implanted to treat RV failure and delay repair surgery.

PIVSD was successfully repaired with surgery after acute heart failure was treated.

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