Impella 2.5 System Supports PCI of Unprotected Left Main

This case is supported by Abiomed.

Patient presentation

A 78-year-old male presented with rapidly progressing angina symptoms and signs of acutely decompensating left ventricular systolic heart failure. Past history included severe coronary artery disease, dilated cardiomyopathy, moderate-severe pulmonary hypertension, severe chronic obstructive pulmonary disease (COPD), ongoing tobacco abuse, and diffuse peripheral vascular disease. In 1977, he had a single saphenous vein graft to his circumflex.

A year prior to presentation, he had coronary angiography performed in the pre-operative setting for a high-risk surgical procedure. This angiography revealed the interval closure of his vein graft as well his native circumflex. His left main coronary artery had moderate stenosis and his left ventriculogram showed severe systolic dysfunction. At that time, the operator and his primary cardiologist felt that it was prudent to attempt medical therapy. 

The patient did reasonably well for about a year, then presented as noted above with severe symptoms. 

A left and right heart catheterization revealed elevated right and left filling pressures, severe pulmonary hypertension, and coronary disease that had progressed. The medical team weighed the options of redo bypass percutaneous coronary intervention (PCI) or continuing medical therapy. It was decided that he posed an inhibitory risk for pulmonary complication from coronary artery bypass graft surgery (CABG), and therefore PCI was recommended in an attempt to relieve symptoms and improve left ventricular function. The patient had severe calcification of his coronary vessels (Figure 1) and the use of rotational atherectomy was required.

Procedure description

An Impella 2.5 catheter (Abiomed) was inserted into the left ventricle via the left common femoral artery and a temporary transvenous pacemaker was inserted via the right common femoral vein. Interventional access was performed via the right common femoral artery. 

Several passes were performed using a 1.75mm burr Rotoblator (Boston Scientific). Pre-dilation was followed by deployment of a drug-eluting stent. Post-dilation was performed using a non-compliant balloon. During the procedure, the Impella 2.5 catheter flow was 2.3ml/minute. The patient tolerated the procedure well without hemodynamic compromise or complications. 

Case outcome

The technical outcome of the procedure was a successful reduction of a calcified, high-grade stenosis in an unprotected left main into a severely diseased left anterior descending coronary artery (LAD) to 0% residual (Figure 2) with no complications. Insertion and removal of large-bore arterial access was done with no bleeding. Intra-procedural use of Impella 2.5 device support resulted in no deviation from the presenting hemodynamic stability.

Revascularization significantly improved the severity and frequency of the patient’s angina. Subsequently, echocardiography performed after discharge showed a modest improvement of left ventricular systolic function.

Device description

The Impella 2.5 microaxial blood pump is percutaneously placed in the left ventricle to provide up to 2.5 liters per minute of non-pulsatile blood flow into the aorta. The pump configuration is unique in that it is inserted through a 13 French (Fr) sheath placed in the femoral artery and the 9 Fr catheter body is passed across the aortic valve to position the inflow port within the left ventricle, while the outflow port and axial flow pump are positioned within the ascending aorta (Figure 3). The catheter is attached to the Automated Impella Controller (Figure 4), which provides continuous output and performance data on a display panel.

Discussion

This case represents the use of Impella 2.5 hemodynamic support in a high-risk patient and a high-risk lesion to more safely, and in a more controlled fashion, complete an appropriate intervention with high probability of clinical benefit to the patient, in terms of angina relief and potential improvement of left ventricular function.