Large Microaxial Circulatory (Impella) Support Through Brachiocephalic Arterial Graft for High-Risk Cardiac Operations and Post Cardiotomy Shock

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Cardiothoracic Resident Case Report Competition 

Farhang Yazdchi (1), Michael Kwon (2), Hari Mallidi (3), Mohamed Keshk (4), Morgan Harloff (1), Borami Shin (2), Sitaram Emani (5), Mark Cunningham (1), Akinobu Itoh (6)

(1) Brigham and Women's Hospital, Boston, MA, (2) N/A, N/A, (3) Brigham and Women’s Hospital, Boston, MA, (4) N/A, Boston, MA, (5) Boston Children's Hospital, Boston, MA, (6) Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Farhang Yazdchi    -  Contact Me
Brigham and Women's Hospital

Michael Kwon    -  Contact Me
N/A

Hari Mallidi    -  Contact Me
Brigham and Women’s Hospital

Mohamed Keshk    -  Contact Me
N/A

Morgan Harloff    -  Contact Me
Brigham and Women's Hospital

Borami Shin    -  Contact Me
N/A

*Sitaram Emani    -  Contact Me
Boston Children's Hospital

Mark Cunningham    -  Contact Me
Brigham and Women's Hospital

*Akinobu Itoh    -  Contact Me
Brigham and Women’s Hospital, Harvard Medical School

Farhang Yazdchi    -  Contact Me
Brigham and Women's Hospital

Objective: The utilization of temporary mechanical circulatory support (MCS) in high-risk cardiac surgery and acute cardiogenic shock has been rapidly increasing, specifically by the large micro-axial pump (Impella 5.5). Surgical grafting to the axillary artery or the ascending aorta are two most common anatomical approaches for the insertion. However, an alternative approach through the brachiocephalic artery enables the Impella insertion 1) through median sternotomy without fluoroscopy during high-risk cardiac operations, and 2) for patients with small axillary artery and/or short aorta which are contraindications for the conventional Impella 5.5 insertion. In this video presentation we describe two cases of Impella 5.5 implantation through brachiocephalic artery for the two distinct scenarios.

Case 1: A 72-year-old male presented with moderate to severe aortic tissue valve regurgitation (Implanted 12 years ago) due to the recent prosthetic valve endocarditis treated medically. His ejection fraction was <20%. Through the redo-sternotomy, a 10-mm Dacron graft was sewn to the brachiocephalic artery and tunneled to the supraclavicular area. Then, a guidewire was parked into the ascending aorta through this graft using transesophageal echocardiography (TEE) guidance. The AVR was then conducted in standard fashion and the guidewire was manually directed into the left ventricle (LV) before the aortotomy closure. After the cross-clamp was released, the Impella 5.5 was passed over the guidewire under TEE guidance without fluoroscopy to the poorly functioning LV. Postoperatively he was mobilized well and separated from the device on POD 7 by ligating the graft through the supraclavicular counter skin incision.

Case 2: Unlike the first case, the impella implantation was not planned but went well for the second case. A 38-year-old female with congenital mitral valve insufficiency, atrial fibrillation, and ventricular septal defect (VSD) with low normal ejection fraction preoperatively. She underwent mitral valve replacement (MVR) with On-X mechanical valve, MAZE procedure, and VSD closure. The operation was complicated by post cardiotomy cardiogenic shock requiring VA-ECMO support. Due to the predominant LV dysfunction, Impella 5.5 was inserted on POD2 with the intention of weaning from VA ECMO and close the chest. Due to the 5mm right axillary artery and short ascending aorta, the brachiocephalic artery (9mm) was chosen to be grafted for Impella 5.5 insertion to secure the safety length for the Impella 5.5 outflow while the chest was still open under TEE and fluoroscopy guidance. On POD4, she was weaned and decannulated from central VA ECMO and the chest was closed, On POD 14 the Impella was removed at the bedside.

Conclusions: Implantation of the Impella 5.5 via brachiocephalic arterial graft is feasible in situations that the chest is already open, or/ and axillary artery is small and unsuitable, or ascending aorta is short. This technique even facilitates efficient insertion without any other incisions (i.e. axillary incision) or fluoroscopy utilization. Although scheduled implantation of Impella 5.5 may provide a better outcome, the pre- and peri-operative patient assessment should be carefully proceeded. Further considerations in patients' disease profiles and anatomical characteristics will help us choose the optimal approach to improve outcomes in this difficult patient population.

Adult Cardiac