Ann Thorac Surg 2008;85:1468-1470. doi:10.1016/j.athoracsur.2007.09.017
© 2008 The Society of Thoracic Surgeons
How To Do It
The Right Axillary Artery Approach for the Impella Recover LP 5.0 Microaxial Pump
Thomas Sassard, MDa,
Aurelien Scalabre, MDa,
Eric Bonnefoy, MD, PhDb,
Ingrid Sanchez, MDb,
Fadi Farhat, MD, PhDa,
Olivier Jegaden, MD, PhDa,*
a Department of Cardiovascular Surgery and Transplantation, Claude Bernard University, Lyon Cedex, France
b Department of Cardiology and Intensive Care, Louis Pradel Hospital, Claude Bernard University, Lyon Cedex, France
Accepted for publication September 11, 2007.
* Address correspondence to Dr Jegaden, Department of Cardiovascular Surgery and Transplantation, Louis Pradel Hospital, 28 Avenue du Doyen Lepine, BP Lyon-Monchat, Lyon Cedex, 69394, France (Email: olivier.jegaden{at}chu-lyon.fr).
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Abstract
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As a ventricular unloading catheter, the Impella Recover LP 5.0 (Abiomed, Danvers, MA) is appropriate for temporary circulatory assistance in severe left ventricular dysfunction. We describe a new implantation approach to the right axillary artery with the aims of avoiding vascular problems due to atherosclerosis of the peripheral arteries and improving patient mobility and rehabilitation during mechanical support.
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Introduction
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The Impella Recover LP 5.0 (Abiomed, Danvers, MA) is a new intravascular microaxial blood pump used for short-term mechanical support in cases of acutely reduced left ventricular function. As a ventricular unloading catheter, it supports the myocardium with up to 5 L/minute for up to 10 days (European Community marked, United States Food and Drug Administration investigational device exemption). The pump has been designed to be inserted by using the Seldinger technique through a cut-down in the femoral artery [1]. We describe a new implantation approach in the right axillary artery with the aims of avoiding vascular problems due to atherosclerosis of the peripheral arteries and improving patient mobility and rehabilitation during mechanical support.
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Technique
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The Impella Recover LP 5.0 (Abiomed) is a miniaturized rotary blood pump (21 French). The pump incorporates a rotor driven by an electric motor with an inflow tip. The pump is placed through the aortic valve and aspirates blood from the left ventricle cavity and expels the blood into the ascending aorta. This device has been designed for the Seldinger implantation technique thanks to a pigtail at the tip of the inflow canula. Under general anesthesia and heparinization (1 mg/kg), the right axillary artery is exposed below the clavicle. An 8-mm vascular graft is sutured end-to-side and clamped closed to the anastomosis. A guidewire is introduced in the device through a specific lumen to the distal pigtail. The device is then introduced into the graft, and an occluding plug around the 9-French driving cable is tied to prevent blood loss through the graft during the implantation maneuvers (Fig 1); the occluding plug allows the driving of the cable and sliding of the guidewire. The clamp is removed. The guidewire is introduced into the axillary artery to the left ventricle cavity, crossing the aortic valve, under fluoroscopic guidance or transesophagal echocardiography. After the guidewire is introduced, the device is then progressively pushed into the graft and introduced into the axillary artery to the left ventricle cavity. The correct position of the device is confirmed by fluoroscopy or transesophageal echocardiography and the pressure signal at the console. The guidewire is then removed. The device is turned on. The graft around the cable is tied, closed to the anastomosis, cut off 1 cm farther, and removed as the occluding plug. The cable sheath is pushed into the remaining graft to the ties to complete hemostasis (Fig 2). The sheath is blocked distally and fixed at the skin to secure the driving cable and pump into position. The surgical approach is closed and the driving cable with the sheath is allowed to exit from the axillary wound. To remove the device, the same approach is used. Only the remaining graft is controlled; the ties around are removed and the device is gently pulled back and out. The graft is clamped and oversewn; then the surgical approach is closed.
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Fig 1. Impella Recover LP 5.0 (Abiomed, Danvers, MA) set on the guidewire is introduced in the graft and an occluding plug around the 9-French driving cable is tied to prevent blood loss during the implantation.
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We have recently used this technique of implantation in 2 patients. The first case was a 61-year-old man with acute cardiogenic shock due to massive anterior infarction. Despite intubation, a high dose of catecholamine and an intraaortic balloon pump, he remained unstable with metabolic disorders. The indication of Impella Recover LP 5.0 implantation was bridge to recovery or bridge to bridge. The device raised cardiac output to 6 L/minute; the catecholamine therapy was stopped the first day after implantation, and the patient was extubated at 7 days after intraaortic balloon pump removal. The patient recovered his mobility, and his rehabilitation started on armchair. Left ventricular function recovered progressively, and the patient was weaned from the pump. The device was removed under local anesthesia 18 days after implantation without complication. The patient was oriented to medical treatment and checked for heart transplantation.
The second case was a 25-year-old man with severe ischemic cardiomyopathy on the waiting list for heart transplantation. Cardiogenic shock occurred progressively, despite inotropic support and an intraaortic balloon pump. The indication of the Impella Recover LP 5.0 implantation was bridge to transplantation. The patient was intubated for the procedure and extubated just after the procedure (Fig 3). The rehabilitation started 2 days later after intraaortic balloon pump removal and the patient had a heart transplantation 14 days after implantation with a good outcome. In this case, we would have considered exchanging the Impella Recover pump for left ventricular assist device long-term support if heart transplantation had been delayed.
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Fig 3. Thoracic x-ray film of the extubated patient shows the pump in the left ventricle, crossing the aortic valve, and the driving cable exiting from the right axillary artery.
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Comment
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Acute heart failure continues to represent a challenge for the application of mechanical circulatory support devices. As a ventricular unloading catheter, the Impella Recover pump is appropriate for temporary circulatory assistance in severe left ventricular dysfunction. The Impella Recover LD100 was first designed for short-term support of the failing heart in post-cardiotomy low-output syndrome with a direct implantation in the ascending aorta [2]. The Impella Recover LP 5.0 (Abiomed) has been designed for Seldinger technique implantation through femoral artery under local anesthesia [1]. The device is simple to insert and does not require systemic anticoagulation. According to the duration of the support, its indications are bridge to recovery, bridge to bridge in patients who are too ill for conventional implantable left ventricular assist devices, and bridge to transplantation when a short waiting time is considered [1, 3]. Axillary implantation through a graft interposition has been previously described for ambulatory intraaortic balloon pump use, allowing to increase patient rehabilitation before transplantation [4], and we propose the same approach for Impella Recover LP 5.0 implantation to avoid the problem of peripheral vascular access in patients with atherosclerosis and to make it possible for mobility and rehabilitation of the patient during the mechanical support. In our preliminary experience, the axillary implantation was done under general anesthesia in one case because the patient was intubated previously and in the second case to make the procedure faster. However, we believe that the procedure is feasible under local anesthesia, as we had done to remove the device in the first case. The technique described using a graft interposition avoids blood loss during the implantation and allows easy repositioning of the device if necessary. The position of the guidewire and then of the pump in the left ventricular cavity is checked by either fluoroscopy in the awake patient or transesophageal echocardiography under general anesthesia. The sheath of the driving cable is very useful to complete the hemostasis around the cable in the short remaining graft and must be fixed at the skin to secure the system at the end of the procedure. The axillary approach allows early and easy mobilization of the patient and has been particularly appreciated by the nurses in the intensive care unit. As soon as the hemodynamic conditions of the patient improve, this approach allows the rehabilitation of the patient. In the two reported cases, the patients were able to get out of bed, rest in an armchair, walk around the room, and undergo kinesitherapy. In post-cardiotomy low-output syndrome, the axillary approach has to be considered to avoid reopening the chest to remove the device. Nowadays, this axillary approach is the reference technique for Impella Recover LP 5.0 implantation in our institution, and we advise its use.
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References
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- LaRocca GM, Shimbo D, Rodriguez CJ, et al. The Impella Recover LP 5.0 left ventricular assist device: a bridge to coronary artery bypass grafting and cardiac transplantation J Am Soc Echocardiogr 2006;19:468e5–7.
- Garatti A, Colombo T, Russo C, et al. Left ventricular mechanical support with the Impella Recover left direct microaxial blood pump: a single-center experience Artif Organs 2006;30:523-528.[Medline]
- Garatti A, Colombo T, Russo C, et al. Different applications for left ventricular mechanical support with the Impella Recover 100 microaxial blood pump J Heart Lung Transpl 2005;24:481-485.[Medline]
- Cochran RP, Starkey TD, Panos AL, Kunzelman KS. Ambulatory intraortic balloon pump use as bridge to heart transplant Ann Thorac Surg 2002;74:746-751.[Abstract/Free Full Text]
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Abstract
Introduction
