Impella 5.5 as Bridge and Mechanical Support Following Simultaneous Heart/Kidney Transplant
Presented During: Welcome Reception and Poster Competition | Sponsored by: TransMedics
University of Wisconsin
Madison, WI
United States - Contact Me
Angie Kristo is a fourth year medical student at the University of Wisconsin School of Medicine and Public Health. She is originally from Milwaukee, Wisconsin and completed her undergraduate degree in neuroscience at the Ohio State University. She has a strong interest in academic medicine and pursuing a surgical specialty.
Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Description
Objectives
Approximately 25-40% of simultaneous heart/kidney transplant (SHKT) recipients require renal replacement therapy (RRT) within 30 days of transplant. Our institution historically performed SHKT in separate operations with a period of resuscitation in the intensive care unit following heart transplantation (HT). In this case of a patient bridged to SHKT with an Impella 5.5, the device was preserved following HT to provide mechanical support and facilitate kidney transplantation in the same operative encounter with the goal of reducing delayed graft function of the kidney.
Methods
Our patient is a 60-year-old man, blood group O, ischemic cardiomyopathy (EF 20%), stage 3b chronic kidney disease due to diabetes, and listed status 5 for combined heart/kidney transplant. Due to worsening hemodynamics (cardiac index 1.7L/min/m2, mean PA pressures 37 mm Hg, and PCWP 28 mmHg) and rising creatinine (Cr 1.8-2.1 mg/dL, eGFR 30 ml/min/1.73 sqm) despite inotropes, a right axillary Impella 5.5 was inserted. After waiting 32 days as status 2, the patient underwent SHKT from a neurologically dead donor whose cause of death was blunt trauma. The donor had normal cardiac function, a KDPI of 9%, normal creatinine, and a small subcapsular hematoma of the kidney. Bicaval heart transplant was performed with a 226 minute ischemia time. The Impella driveline was cross-clamped with the aorta and preserved during cardiectomy. During the aortic anastomosis, the Impella was flushed with heparinized saline and then repositioned across the aortic valve. Following reperfusion, the recipient was able to be weaned from bypass without issue with a cardiac index of 2.5 L/min/m2. At the end of the HT, the patient was supported with the Impella on p7, flowing 4 liters, and 0.08 mcg/kg/min epinephrine primarily for right heart support. The kidney was transplanted in the iliac fossa with 10 hours cold ischemia and 32 minutes out of ice time and thymoglobulin induction immediately following chest closure.
Results
After an uneventful operative course, the patient left the OR with 0.06 mcg/kg/min epinephrine, 0.04 mcg/kg/min norepinephrine, 0.04 units/kg/min vasopressin, and 5 mcg/kg/min dobutamine, along with Impella support. He was extubated and out of bed 18 hours after surgery, with a single agent inotrope (5 mcg/kg/min of dobutamine), and standard triple immunosuppression with tacrolimus, mycophenolate, and steroids. Heart and kidney function were excellent with immediate production of urine. The Impella was weaned and removed by postoperative day 4 and inotropes discontinued by postoperative day 7. He produced more than 2.5 liters of urine daily, with creatinine peaking at 2.39 mg/dL and ending at 0.9 mg/dL, without needing RRT. He was discharged on postoperative day 15 with an uneventful course and seen in outpatient follow-up with excellent heart and kidney graft function.
Conclusions
In our patient who was bridged to SHKT with an Impella 5.5, leaving the device for temporary mechanical support allowed for kidney transplant in the same operative encounter, early mobilization, reduction of vasoactive agents, and importantly, may have reduced the risk of delayed graft function and need for RRT. In select patients, this strategy may be considered to improve outcomes following SHKT.
Authors
Angela Kristo (1), Romulo Fajardo (2), John Harrison (3), Paul Tessman (4), Joshua Hermsen (5), Nikole Neidlinger (6), Yu Xia (7)
Institutions
(1) N/A, Madison, WI, (2) University of Wisconsin-Department of Cardiothoracic Surgery, Madison, WI, (3) University of Wisconsin Department of Anesthesiology, Madison, WI, (4) University of Wisconsin Department of Cardiothoracic Surgery, Madison, WI, (5) University of Wisconsin, Madison, Madison, WI, (6) University of Wisconsin Department of Transplant Surgery, Madison, WI, (7) Division of Cardiothoracic Surgery, University of Wisconsin Department of Surgery, Madison, Madison, WI
Approximately 25-40% of simultaneous heart/kidney transplant (SHKT) recipients require renal replacement therapy (RRT) within 30 days of transplant. Our institution historically performed SHKT in separate operations with a period of resuscitation in the intensive care unit following heart transplantation (HT). In this case of a patient bridged to SHKT with an Impella 5.5, the device was preserved following HT to provide mechanical support and facilitate kidney transplantation in the same operative encounter with the goal of reducing delayed graft function of the kidney.
Methods
Our patient is a 60-year-old man, blood group O, ischemic cardiomyopathy (EF 20%), stage 3b chronic kidney disease due to diabetes, and listed status 5 for combined heart/kidney transplant. Due to worsening hemodynamics (cardiac index 1.7L/min/m2, mean PA pressures 37 mm Hg, and PCWP 28 mmHg) and rising creatinine (Cr 1.8-2.1 mg/dL, eGFR 30 ml/min/1.73 sqm) despite inotropes, a right axillary Impella 5.5 was inserted. After waiting 32 days as status 2, the patient underwent SHKT from a neurologically dead donor whose cause of death was blunt trauma. The donor had normal cardiac function, a KDPI of 9%, normal creatinine, and a small subcapsular hematoma of the kidney. Bicaval heart transplant was performed with a 226 minute ischemia time. The Impella driveline was cross-clamped with the aorta and preserved during cardiectomy. During the aortic anastomosis, the Impella was flushed with heparinized saline and then repositioned across the aortic valve. Following reperfusion, the recipient was able to be weaned from bypass without issue with a cardiac index of 2.5 L/min/m2. At the end of the HT, the patient was supported with the Impella on p7, flowing 4 liters, and 0.08 mcg/kg/min epinephrine primarily for right heart support. The kidney was transplanted in the iliac fossa with 10 hours cold ischemia and 32 minutes out of ice time and thymoglobulin induction immediately following chest closure.
Results
After an uneventful operative course, the patient left the OR with 0.06 mcg/kg/min epinephrine, 0.04 mcg/kg/min norepinephrine, 0.04 units/kg/min vasopressin, and 5 mcg/kg/min dobutamine, along with Impella support. He was extubated and out of bed 18 hours after surgery, with a single agent inotrope (5 mcg/kg/min of dobutamine), and standard triple immunosuppression with tacrolimus, mycophenolate, and steroids. Heart and kidney function were excellent with immediate production of urine. The Impella was weaned and removed by postoperative day 4 and inotropes discontinued by postoperative day 7. He produced more than 2.5 liters of urine daily, with creatinine peaking at 2.39 mg/dL and ending at 0.9 mg/dL, without needing RRT. He was discharged on postoperative day 15 with an uneventful course and seen in outpatient follow-up with excellent heart and kidney graft function.
Conclusions
In our patient who was bridged to SHKT with an Impella 5.5, leaving the device for temporary mechanical support allowed for kidney transplant in the same operative encounter, early mobilization, reduction of vasoactive agents, and importantly, may have reduced the risk of delayed graft function and need for RRT. In select patients, this strategy may be considered to improve outcomes following SHKT.
Authors
Angela Kristo (1), Romulo Fajardo (2), John Harrison (3), Paul Tessman (4), Joshua Hermsen (5), Nikole Neidlinger (6), Yu Xia (7)
Institutions
(1) N/A, Madison, WI, (2) University of Wisconsin-Department of Cardiothoracic Surgery, Madison, WI, (3) University of Wisconsin Department of Anesthesiology, Madison, WI, (4) University of Wisconsin Department of Cardiothoracic Surgery, Madison, WI, (5) University of Wisconsin, Madison, Madison, WI, (6) University of Wisconsin Department of Transplant Surgery, Madison, WI, (7) Division of Cardiothoracic Surgery, University of Wisconsin Department of Surgery, Madison, Madison, WI