Impella 5.0 Allows for OPCAB in Spite of Severely Impaired Left Ventricular Function

Background: Off-pump coronary artery bypass grafting (OPCAB) with minimized aortic manipulation avoids extracorporeal circulation-associated complications, and particularly stroke in patients with severe aortic atherosclerosis. While the vast majority of patients are eligible for OPCAB, patients with severely impaired left ventricular function are challenging. We report on our first series of OPCAB under Impella 5.0 support in patients with decompensating left ventricles.

Method: Eight patients with three-vessel coronary artery disease and severely impaired left ventricular function (ejection fraction (LVEF) 29.9 ± 10.1%) underwent OPCAB with minimized aortic manipulation and hemodynamic support by Impella 5.0 cannulated via vascular prosthesis to the right axillary artery. In-hospital as well as follow-up data were analyzed.

Results: All patients received complete surgical collateralization (2.8 ± 0.9 coronary anastomoses; 100% with left internal thoracic artery graft); the cut-suture time amounted to 349 ± 50 minutes; and hemodynamics and cerebral oxygen saturation were adequate throughout. One patient required rethoracotomy due to bleeding. Maximum creatine kinase-MB after surgery was 37.9 ± 12.2 U/L. Postoperatively, the left ventricular function increased (LVEF 37.3 ± 7.5% with p = 0.008 vs. preoperative LVEF), and seven patients were successfully weaned from Impella support within 6.4 ± 4.0 days, while one patient without sufficient improvement of the left ventricular function required implantation of a left ventricular assist device. Patients were discharged from the intensive care unit after 232 ± 157 hours, and from the hospital after 23.1 ± 9.1 days. After a mean follow-up period of 19 months, freedom from death, stroke, myocardial infarction, or re-revascularization was 100%, whereas one patient required heart transplantation at 9 months.

Conclusion: Utilizing Impella 5.0 support, OPCAB with minimized aortic manipulation becomes feasible even in the presence of severely impaired left ventricular function. Especially patients with additional high risk of extracorporeal circulation-associated complications, particularly stroke due to aortic atherosclerosis, may profit from the presented approach. Importantly, Impella 5.0 therapy allows for adequate blood flow and simultaneous left ventricular unloading during the postoperative state of inflammatory activation that typically requires enhanced cardiac output. Thus, Impella 5.0 also enables timely and gentle weaning from mechanical circulatory support.

Publication History

Article published online:
28 January 2023