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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Nothing Like a Good Assistant
Case#: 17
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
59 yo with history of myocardial infarction. Patient underwent a failed coronary stent procedure. Patient presents to the OR for a CABG w/ECC. The patient has a history of HTN, DM, and mild COPD.

What is the diagnosis?
What is the device?
Please discuss how the device works, its effects and how it compares to other similar devices.
Did the device work in this case?

Case Discussion/CME Questions
The patient has a RCA lesion that resulted in a right ventricular, inferior wall, and inferoseptal wall akinesis. The device is an axial flow pump that was percutaneously inserted into the left ventricle via the aortic valve and is called an Impella device.

The Impella device has been used in the cateterization lab, the ICU, and in the cardiac operating room to provide unloading of the left ventricle by a high speed rotor that can achieve cardiac outputs up to 2.5 l/min (5.0 l/m in the larger device). It provides superior unloading of the left ventricle compared to an IABP (0.5 l/min) however, in one study the Impella device did not result in improved survival compared to an IABP. The Impella and an IABP have been used together for cardiogenic shock. In dogs the Impella provided better pressure-volume loops than ECMO. The Impella device has been used in high risk PCI, high risk CABG, and in the ICU for LV support. While AS remains a relative contraindication, the Impella device has been used in a patient with severe aortic stenosis. The Impella device has been used in post-myocardial infarction VSD to support the left ventricle.

The effect of the Impella, which providing higher cardiac output, is the unloading of the ventricle during diastole.  The decreased LVEDD and LVEDP would help improve the microcirculation of the left ventricle and the diastolic wall stress. The coronary blood flow increased by 47% in sheep, whereas the coronary blood flow increased by 13% with an IABP.

The Impella device has been used in patients with right ventricular failure and resulted in a decrease of the CVP.

Complications are infection, bleeding, thrombosis, left ventricular wall rupture, and functional mitral stenosis where the device impinges the mitral valve anterior leaflet motion.

In this case, the Impella device was helping the right ventricle. After the RCA was bypassed and the Impella device was removed, the RV free wall, inferior wall, and inferoseptal wall has worse RWMA compared to preop.
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Web Links/References
Acute complication due to impella 2.5 device (superficial femoral artery thrombosis): managed successfully with novel aspiration thrombectomy catheter (pronto v3).
Left Ventricular Mechanical Support with Impella Provides More Ventricular Unloading in Heart Failure than Extracorporeal Membrane Oxygenation.
Use of the Impella 2.5 in high-risk percutaneous coronary intervention.
Successful combined use of Impella Recover 2.5 device and intra-aortic balloon pump support in cardiogenic shock from acute myocardial infarction.
Impella Recover 5.0 assisted coronary artery bypass grafting.
Prophylactic use of intra-aortic balloon pump for high-risk percutaneous coronary intervention: will the Impella LP 2.5 device show superiority in a clinical randomized study?
Hemodynamic support using the Impella 2.5 catheter system during high-risk percutaneous coronary intervention in a patient with severe aortic stenosis.
Successful high-risk percutaneous coronary revascularization using Impella Recover LP 5.0 l/min.
The use of the Impella LP 2.5 percutaneous microaxial ventricular assist device as hemodynamic support during high-risk abdominal surgery.
Effects of mechanical left ventricular unloading by Impella on left ventricular dynamics in high-risk and primary percutaneous coronary intervention patients.
Temporary right ventricular support with Impella Recover RD axial flow pump.
Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials.
Role of Impella 2.5 heart pump in stabilizing diastolic aortic pressure to avert acute hemodynamic collapse during coronary interventions.
Potential role of the Impella Recover left ventricular assist device in the management of postinfarct ventricular septal defect.
Improved microcirculation in patients with an acute ST-elevation myocardial infarction treated with the Impella LP2.5 percutaneous left ventricular assist device.
Experience with the Impella recovery axial-flow system for acute heart failure at three cardiothoracic centers in Sweden.
A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction.
Functional mitral stenosis: a rare complication of the Impella assist device.
Impella used for hemostasis by left ventricular unloading, in a case with left ventricular posterior wall rupture.
Combined Impella and intra-aortic balloon pump support to improve both ventricular unloading and coronary blood flow for myocardial recovery: an experimental study.
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