Circulatory Management with Impella Assistance During Off-Pump Coronary Artery Bypass Grafting for Cardiogenic Shock: A Report of Two Cases

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The combination of initial Impella therapy, Impella-supported coronary artery bypass grafting (ISCAB), and postoperative Impella therapy providing antegrade perfusion in myocardial infarction can prove effective. We investigated strategies for Impella stabilization in ISCAB, particularly during peripheral circumflex branch anastomosis. Case 1 was a 70-year-old man treated with an Impella 2.5, followed by urgent ISCAB on the day of hospitalization, for a left main trunk lesion. Use of an apical suction device to position the heart to expose an obtuse marginal branch caused Impella obstruction by applying suction to the left ventricular wall, interrupting revascularization; however, one revascularization was achieved. Case 2 was a 79-year-old man treated with an Impella CP for a three-vessel lesion until ISCAB 4 days later. The Impella was stabilized with appropriate positioning by adjusting the bed angle, minimal heart compression with a deep pericardial stitch without pulling on the cardiac apex, and sufficient preload, even during posterolateral branch anastomosis. Four revascularizations were eventually achieved. Multiple innovations to prevent Impella contact with the left ventricle as described herein improve ISCAB safety, particularly during peripheral circumflex branch anastomosis.