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Ann Thorac Surg 2009;88:271-273. doi:10.1016/j.athoracsur.2008.12.036
© 2009 The Society of Thoracic Surgeons
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Case Reports

Successful Treatment of Heart Failure due to Acute Transplant Rejection With the Impella LP 5.0

Gordan Samoukovic, MDa, Talal Al-Atassi, BSca, Cristian Rosu, MDa, Nadia Giannetti, MDb, Renzo Cecere, MDa,*

a Division of Cardiothoracic Surgery, McGill University Health, Montreal, Quebec, Canada
b Division of Cardiology, McGill University Health, Montreal, Quebec, Canada

Accepted for publication December 1, 2008.

* Address correspondence to Dr Cecere, 687 Pine Ave West, Rm S8.45, Montreal, Quebec, H3A 1A1, Canada (Email: renzo.cecere{at}muhc.mcgill.ca).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Cardiogenic shock resulting from transplant rejection is a serious complication with high mortality and morbidity. Often resistant to maximal medical therapy, this condition frequently requires mechanical circulatory support until recovery or retransplantation. We present a 52-year-old patient with multiorgan failure secondary to acute graft rejection after orthotopic heart transplantation. Maximal medical therapy was not successful, and the patient was bridged to recovery with an Impella LP 5.0 (Abiomed Inc, Danvers, MA) left ventricular assist device (LVAD). The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged 3 weeks after LVAD removal and remains clinically stable.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Mechanical circulatory support after orthotopic heart transplantation (OHT) has been used as therapy for primary graft and right-sided heart failure, as well as for low-output states resulting from chronic and acute rejection that is resistant to medical therapy [1]. A variety of devices have been used for ventricular support in these patients, ranging from intraaortic balloon pumps (IABP) to more permanent systems such as the Abiomed BVS5000 (Abiomed Inc, Danvers, MA) [2]. Despite recent technical advancements in the design of left ventricular assist devices (LVADs), mechanical circulatory support after OHT remains associated with serious complications and high mortality.

The Impella LP 5.0 LVAD (Abiomed Inc) is a novel, minimally invasive ventricular unloading system. It has been used to provide short-term circulatory support for patients with acute heart failure from myocardial infarction or viral myocarditis and in acute deterioration secondary to ischemic and dilated cardiomyopathies [3] or after coronary artery bypass grafting (CABG) [4].

A 52-year-old woman presented with dyspnea, tachycardia, abdominal pain, nausea, and vomiting. The patient had a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and two cerebrovascular accidents. She had undergone OHT 5.5 years before for ischemic cardiomyopathy. She had been compliant with the antirejection regimen consisting of cyclosporine (60 mg twice daily) and mycophenolate mofetil (1000 mg twice daily), and had not shown any signs of rejection on routine follow-up myocardial biopsy specimens, the latest of which was 4 months before the presentation.

Clinical investigations suggested acute heart failure with a LV ejection fraction (LVEF) of 0.10 and markedly elevated levels of liver enzymes, serum creatinine, and lactate. Despite aggressive antirejection medication with antithymocyte globulin, methylprednisolone, mycophenolate mofetil, and cyclosporine, as well as inotropic support with dobutamine (10 µg/kg/min), adrenaline (15 µg/kg/min), and norepinephrine (15 µg/min), her systolic blood pressure remained below 90 mm Hg, and the cardiac index was below 1.2 L/min/m2. An IABP was introduced but yielded only marginal improvements in hemodynamic variables. Arterial blood gas analysis revealed lactic acidosis (pH, 7.23; serum lactate, 12.3 mmol/L).

A microaxial LVAD Impella LP 5.0 was inserted in the cardiac catheterization suite through a left femoral artery cutdown and advanced across the aortic valve under fluoroscopic guidance. The pump flow was increased, yielding a total cardiac index of 3.6 to 3.9 L/min/m2. At the same time, a myocardial biopsy specimen was obtained that later revealed grade 2R cellular rejection.

In the intensive care unit, acidosis corrected within 10 hours, and the serum lactate level normalized within 24 hours (Fig 1). The concentration of liver enzymes, signifying hepatic cellular damage (Fig 2), and serum creatinine (Fig 1) peaked at 72 hours after insertion, but approached normal values during the next 4 days. The IABP was removed approximately 30 hours later, at which time inotropic support with dobutamine (5 to 7.5 µg/kg/min) and Levophed (4 to 12 µg/min) was continued.


Figure 1
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  		Fig 1. Variation of concentration of serum creatinine (squares) and lactate (diamonds) with time while the patient received Impella LP 5.0 support (Abiomed Inc, Danvers, MA). The red and blue arrows represent the times of the left ventricular assist device insertion and removal, respectively.

 

Figure 2
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  		Fig 2. Variation of serum alanine aminotransferase (ALT; squares) and aspartate aminotransferase (AST; diamonds) with time while the patient received Impella LP 5.0 support (Abiomed Inc, Danvers, MA). The red and blue arrows represent the times of the LVAD insertion and removal, respectively.

 
The Impella performance was optimized to provide an average output of 4.6 L/min (range, 3.4 to 5 L/min). During support, cardiac function was evaluated echocardiographically. The LVEF improved from 0.15 immediately after insertion to 0.40 just before removal of the LVAD. The patient required 10 U each of platelets and red blood cells and 15 U of plasma.

With stable hemodynamics and objective evidence of improved perfusion while the patient was receiving minimal inotropic support, the Impella LP 5.0 was removed 168 hours after insertion. The patient was extubated 3 days later. During hospitalization, she was treated for aspiration pneumonia and Clostridium difficile colitis, but was discharged 3 weeks later, at which time her LVEF was 0.50. Currently, she is well and is being monitored for a solitary pulmonary nodule discovered incidentally.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Acute heart failure, regardless of cause, represents a major therapeutic challenge. During the last decade, the hospital survival rate of patients receiving circulatory support in the context of acute heart failure has not changed dramatically and ranges from 20% to 40%, regardless of the device used [4]. This article documents the successful treatment of cardiogenic shock secondary to acute transplant rejection using the Impella LP 5.0 microaxial support system. Microaxial systems have previously been used to bridge patients to recovery or transplant [3–5] or during percutaneous coronary intervention in high-risk patients [5].

Cardiac surgical experience with the Impella LP 5.0 is limited, but in this transplant recipient, it was effective in providing hemodynamic support during treatment of acute graft rejection associated with multiorgan failure. It achieves maximal nonpulsatile flow rates of 5 L/min while increasing native cardiac output substantially.

This LVAD has numerous potential advantages, including ease of implantation (catheterization laboratory or intensive care unit, without cardiopulmonary bypass), lower cost, similar survival rates compared with other circulatory support devices [5], low complication rates, and high-output ventricular support. Although a need for repositioning of the pump has been documented [6], no aortic valvular injuries have been reported to date.

Initial studies [5, 6] and our experience suggest a low incidence of hemolysis, occurring primarily in the first 72 hours of support. Our patient experienced an average daily hemoglobin decrease of 10g/L during this early period, after which hemoglobin remained stable. The serum lactate dehydrogenase level, however, remained in the upper limits of normal during the entire time of support. Mechanically induced thrombocytopenia was mild and caused no significant bleeding.

At this time, the Impella LP 5.0 is intended to provide circulatory support up to 10 days, after which more definitive therapy is required. Regardless of these early complications and limitations, this LVAD merits further study in defining its role in the armamentarium for temporary circulatory support in carefully selected patients bridged to transplantation, permanent VAD, or recovery.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Minev PA, El-Banayosy A, Minami K, et al. Differential indication for mechanical circulatory support following heart transplantation Intensive Care Med 2001;27:1321-1327.[Medline]
  2. Petrofski JA, Patel VS, Russell SD, MJilano CA. BVS5000 support after cardiac transplantation J Thorac Cardiovasc Surg 2003;26:442-447.
  3. LaRocca GM, Shimbo D, Rodriguez CJ, et al. The Impella Recover LP 5.0 LVAD: a bridge to coronary artery bypass grafting and cardiac transplantation J Am Soc Echocardiogr 2006;19486e5-e7.
  4. Rossiter-Thornton M, Arun V, Forrest AP, Bayfield MS, Wilson MK. Left ventricular support with the Impella LP 5.0 for cardiogenic shock following cardiac surgery Heart Lung Circ 2008;17:243-245.[Medline]
  5. Siegenthaler MP, Brehm K, Strecker T, et al. The Impella Recover microaxial assist device reduces mortality for postcardiotomy failure: a three-center experience J Thorac Cardiovasc Surg 2004;127:812-822.[Abstract/Free Full Text]
  6. Henriques JPS, Remmelink M, Baan J, et al. Safety and feasibility of elective high-risk percutaneous coronary intervention procedures with left ventricular support of the Impella Recover LP 2.5 Am J Cardiol 2006;97:990-992.[Medline]



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This Article
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Renzo Cecere
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Related Collections
Right arrow Mechanical Circulatory Assistance
Right arrow Transplantation - heart

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