SHOCK5: Utilization of an RP Flex Impella to support Right Ventricular Dysfunction post Left Ventricular Assist Device Placement

Background: Right ventricular dysfunction (RVD) during Left Ventricular Assist Device (LVAD) placement is associated with increased morbidity and mortality. Right Ventricular Assist Device (RVAD) implantation has been shown to reduce the severity of RVD and can improve overall outcomes. We describe the first use of the RP Flex Impella (Abiomed, Danvers MA) RVAD to support RVD during durable LVAD HeartMate 3 implantation(Abbott, Chicago, IL). Case: A 68 year old female with a history of postpartum cardiomyopathy on home inotropic support for 4 years presented with acute exacerbation of heart failure in the setting of sustained ventricular tachycardia. She was evaluated for LVAD however preoperatively there were concerns for risk of RVD due to pulmonary artery pressure index (PAPI) 1.5 and echocardiogram with moderate right ventricular (RV) dilation and significantly reduced function which had progressed as compared to prior assessments. It was decided during the pre implant meeting to support the RV given borderline parameters despite high dose inotropic support. The RP flex impella was placed via the right internal jugular vein and provided 2.8L support. A sodium bicarbonate purge was utilized instead of heparin due to bleeding concerns. By postoperative day (POD) 1 epinephrine and inhaled nitric oxide were successfully titrated down to facilitate early extubation and systemic heparin was started with a goal PTT 50-60 along with aspirin 81mg. Central venous pressure (CVP) remained 8-12mmHg with PAPI 1.2-1.9 over the next few days. RV function on echo remained mildly reduced and LVAD parameters and hemodynamics were stable. Based on the ability to wean inotropes with stable hemodynamics, formal wean occurred on POD4 with reduction to 1.5L flow. Hemodynamics remained unchanged with CVP 10, PA 30/15, PAPI 1.5. Low dose milrinone remained for RV support and the Impella was removed POD 5 at bedside without complication. Post removal RV dilation and drop in PIs resulted in iNO therapy, which was quickly transitioned to sildenafil. Inotropes were fully weaned off POD 12 and the patient was discharged to acute rehab on POD 16 off inotropes and on sildenafil. Throughout this course, renal function remained within the patient’s normal range and the patient was ambulatory from POD 6. Conclusion: This experience describes the first use of RP flex impella to support RVD during durable LVAD placement. The RP flex impella offers a small, percutaneous option for RV support with ease of use and easy bedside removal due to small sheath size. Early use of the RP flex, preventing further sequelae of RVD allowed for adequate support, bypassing the need for surgical RVAD and thus a shorter recovery than traditionally required. Additionally this case adds to the growing literature of RVAD utilization to improve outcomes in patients with marginal RV function for a successful durable LVAD.