Off-Pump HeartMate 3 LVAD Implantation via Left Thoracotomy to Descending Aorta: Transition from Transaxillary Impella 5.0 LVAD

Case Report

Ann Hematol Oncol. 2021; 8(7): 1352

Off-Pump HeartMate 3® LVAD Implantation via Left Thoracotomy to Descending Aorta: Transition from Transaxillary Impella 5.0® LVAD

Luciano R¹, Arce A², Tuluca A², Bozorgnia B², Bonita R², Banka S², Hamshari YA², Robbins T², Mossayebi MH² and Samuels L³*

1Stockton University, Galloway, NJ, USA

2Departsments of Cardiothoracic Surgery and Cardiology, Albert Einstein Medical Center, Philadelphia, PA, USA

2Departsment of Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia, PA, USA

*Corresponding author: Louis Samuels, Department of Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia, PA, USA

Received: April 11, 2021; Accepted: May 17, 2021; Published: May 24, 2021


A 62-year-old man with a prior history of Coronary Artery Bypass Grafting (CABG) presented in cardiogenic shock. A percutaneous left femoral Impella CP® Left Ventricular Assist Device (LVAD) was placed with modest improvement in hemodynamics. The LVAD was upgraded to an open right transaxillary Impella 5.0® with hemodynamic stabilization. Cardiacfunction was assessed with serial echocardiography demonstrating persistent severe left ventricular dysfunction. In view of previous CABG with patent Left Internal Mammary Artery (LIMA) graft the decision was made to place a HeartMate 3® LVAD via left thoracotomy with LV apical inflow and descending aortic outflow. This approach was completed without the need for Cardiopulmonary Bypass (CPB). The postoperative course was uneventful and discharge to a rehabilitation center occurred on the ninth postoperative day.

Keywords: Coronary Artery Bypass Grafting (CABG); Left Ventricular Assist Device (LVAD); Cardiogenic shock


Among the indications for the use of a Left Ventricular Assist Device (LVAD) is Cardiogenic Shock (CS). LVADs may be shortterm (days to weeks), intermediate-term (weeks to months), or longterm (months to years). Short and intermediate term LVADs tend to be utilized as a Bridge-to-Recovery (BTR). Long-term devices are used as a Bridge-to-Transplant (BTT) or Destination Therapy (DT). Patients presenting in acute cardiogenic shock may or may not recover native heart function. As such, multiple LVADs may be necessary to maintain hemodynamic support until a final endpoint is determined.

The incidence of cardiogenic shock following an acute Myocardial Infarction (MI) ranges between 5% and 15% with an average of 7.5% [1]. The mortality associated with acute MI with CS approaches 80%, mirroring the mortality associated with post-cardiotomy shock requiring multiple high dose inotropes [2]. The treatment options for acute MI-CS ranges from intravenous vasopressors/ inotropes to Extra-Corporeal Membrane Oxygenation (ECMO) with theuse of short-term LVAD support as a bridge to recovery, bridge to transplant, or bridge to a long-term device. The purpose of this paper is to describe a complex case of acute MI-CS in which several LVAD technologies were utilized to minimize surgical risk and maximize hemodynamic support. The transition from a shortterm Impella® (Abiomed, Inc., Danvers, MA, USA) to a long-term HeartMate 3® (Abbott Laboratories, Abbott Park, IL, USA) LVAD via left thoracotomy to descending aorta without the need for cardiopulmonary bypass is a novel approach for this complex case.

Case Presentation

A 62-year-old-male presented with shortness of breath and chest pain for 5 days prior to admission. His past medical history consisted of Coronary Artery Disease (CAD), Coronary Artery Bypass Grafting (CABG), active tobacco use, and type 2 diabetes. Upon arrival to the emergency room, he was tachypneic, tachycardic, and hypoxic. His extremities were cool to the touch. A chest CT was obtained showing pulmonary edema. The EKG showed ST depressions in anterior and inferior leads with T wave inversions and ST elevations in lead I and aVL. Echocardiography demonstrated 30% (EF) with hypokinesis at the apex and septum. He was taken to the cardiac catheterization lab where he Ejection Fraction required intubation, defibrillation, chest compressions and chemical resuscitation. Percutaneous placement of an Impella CP® via the left femoral artery was necessary. Coronary angiography revealed diffuse multi-vessel CAD not amenable to Percutaneous Coronary Intervention (PCI) or CABG. Although marginally stabilized, it was determined that the Impella CP® was not sufficient to maintain optimal hemodynamics. A right transaxillary Impella 5.0® was placed in the hybrid catheterization lab together with interventional cardiology. Once stable, the Impella CP® was removed from the left femoral artery. Serial echocardiography over the next two weeks demonstrated persistent Left Ventricular (LV) dysfunction with Impella 5.0® dependence. The decision was made to transition to the HeartMate 3® implantable LVAD. In view of the previous CABG surgery with a patent LIMA graft, an alternative implant approach was utilized.