The “Double-Barrel” Impella CP (DBCP): A Novel Option in the Mechanical Circulatory Support Toolbox
Presenter
Alec Vishnevsky, M.D., Thomas Jefferson University Hospital, Philadelphia, PA
Alec Vishnevsky, M.D.1, Tanuka Datta, MD2, Howard T Massey, MD1 and Eric M. Gnall, D.O.3, (1)Thomas Jefferson University Hospital, Philadelphia, PA, (2)Thomas Jefferson University, Philadelphia, PA, (3)Lankenau Medical Center, Wynnewood, PA
Title
The “Double-Barrel” Impella CP (DBCP): A Novel Option in the Mechanical Circulatory Support Toolbox
Introduction
Optimal management of patients presenting with cardiogenic shock (CS) remains challenging, and guidelines provide limited recommendations with respect to temporary mechanical circulatory support (tMCS) device selection. Specific device selection can be challenging, especially with limited vascular access options. We present a patient with worsening cardiogenic shock secondary to left main thrombosis with limited vascular access who was stabilized with two simultaneous Impella CPs.
Clinical Case
64 year old large male presented to an outside hospital with left main (LM) thrombosis. An intra-aortic balloon pump (IABP) was placed emergently for hemodynamic support. He underwent percutaneous coronary intervention with aspiration thrombectomy complicated by ventricular tachycardia. His IABP was exchanged for an Impella CP via the left femoral artery. A transthoracic echocardiogram (TTE) revealed severe global hypokinesis. He subsequently developed worsening CS despite Impella support. Right heart catheterization revealed RA 12 mmHg, PCWP of 34 mmHg, and cardiac index (CI) 1.8. His end-organ function worsened, and he was transferred to our institution for further management. On arrival, TTE demonstrated EF ~5% with normal RV. Hemodynamics included RA 12, CI 1.5, cardiac power 0.4, and lactate of 4.3 despite Dobutamine infusion and adequate flows on the Impella CP. Following Shock Team discussion, he was brought to the operating room for upgrade to Impella 5.0. However, left subclavian and femoral artery diameters following surgical cut-down were <5mm. Alternative MCS options were discussed, but he was not a candidate for central or peripheral ECMO. With limited support options and his clinical course deteriorating, a second Impella CP was emergently placed in a “double-barrel” fashion (DBCP) via surgical graft to left subclavian artery in tandem with the previous device. The 2 devices provided 5-6 L/min of summative flow. Following insertion of the second device, vasopressor and inotrope support was completely weaned, CI increased to 3.0, and clinical course stabilized.
Discussion
To our knowledge, we present a novel method of percutaneous LV support using two simultaneous Impella CP devices (DBCP), which work in tandem to provide up to 6.0 L/min of flow. Due to severe LV dysfunction, the patient’s cardiac output was determined exclusively by the flow of the Impella CP (CPO of 0.4), and he required additional circulatory support. His subclavian\femoral artery sizes were prohibitive for upgrade to Impella 5.0 or VA ECMO. Theoretical risks of placing two Impellas in a single LV include magnetic interactions between motors and competing inflow ports in close proximity. Once the second Impella was inserted, a flow alarm occurred on both consoles requiring device repositioning such that the ventricular inflow ports were offset. Each device then provided between 2.5 and 3L/min of flow for a total of 5-6L/min. There was no significant aortic insufficiency. This is one of 4 total CS patients in our experience effectively managed using this technique. Successful management of CS patients requiring temporary MCS with limited vascular access can be challenging. Our case illustrates a novel concept to be added to the toolbox of tMCS options.