Insertion of Impella^® in a Patient With an Evolut^TMPRO Prosthesis

An 88-year-old woman was admitted to Saiseikai Kumamoto Hospital with dyspnea due to severe aortic stenosis. Because of her advanced age and high surgical risk score, we performed transfemoral transcatheter aortic valve implantation (TAVI) using a 26-mm Evolut^TMPRO (Medtronic) valve. Immediately after valve implantation, the patient experienced hemodynamic collapse with severe mitral regurgitation (MR). Although an intra-aortic balloon pump was inserted, the patient remained in severe cardiogenic shock. We then inserted the Impella CP^® pump (ABIOMED) into the left ventricle through the transcatheter valve, cognizant of the risk of destroying the pump. After insertion of the Impella^® pump, the patient’s hemodynamic condition improved immediately and the degree of MR decreased to mild. Angiography showed that the Impella^® outlet was in an appropriate position, above the distal stent of the Evolut^TMPRO (Figure A). We were then able to safely manage the Impella^® device using repeated transthoracic echocardiography to confirm the position of the inlet (Figure B) and chest radiography to detect the position of the outlet and the Evolut^TMPRO prosthesis (Figure C). Because the patient’s hemodynamics and mild MR were maintained, we could decrease the assist level of the Impella^® pump and stop the inotropic agent. However, the patient’s condition deteriorated because of sepsis, and she died on Day 5 after TAVI.

Figure.

(A) Angiography showing the position of the Impella^® pump and Evolut^TMPRO valve. (B) Transthoracic echocardiography showing the Impella^® inlet (arrow). (C) Chest radiography demonstrating the position of the Impella^® pump and Evolut^TMPRO valve. (D) The Impella^® pump. The black arrow indicates the inlet, whereas the red arrow indicates the outlet. (E) Impeller blades at the Impella outlet.

The Impella^® device (Figure D) is a percutaneous mechanical circulatory support system used for cardiogenic shock.¹ To the best of our knowledge, there have been no patients in Japan with an Evolut^TMPRO in place in whom an Impella^® pump was subsequently implanted. There is a potential for an interaction between the Impella^® motor housing at the outlet with the distal stent of the Evolut^TMPRO, resulting in destruction of the pump’s impeller blades (Figure E).

Disclosures

None.

Reference

• 1.   Nakamura M, Imamura T, Ueno H, Kinugawa K. Current indication and practical management of percutaneous left ventricular assist device support therapy in Japan. J Cardiol 2020; 75: 228–232.