Utilisation \ue9lective de l\u2019Impella pour un syndrome de bas d\ue9bit postop\ue9ratoire apr\ue8s remplacement valvulaire aortique

Approximativement 1% de proc\ue9dures de chirurgie cardiaque sont compliqu\ue9s par une syndrome de bas d\ue9bit postop\ue9ratoire (SBDP). L\u2019Impella est un syst\ue8me axial d\u2019assistance ventriculaire, qui peut \ueatre utilis\ue9 comme \u201cbridge to recovery\u201d. Nous pr\ue9sentons un cas du remplacement valvulaire aortique (RVA), compliqu\ue9 par une SBDP et trait\ue9 avec une utilisation elective d\u2019un Impella. Un patient de 55 ans a \ue9t\ue9 hospitalis\ue9 chez notre service pour une insuffisance aortique severe avec une mauvaise fraction d'\ue9jection du ventricule gauche (FEVG=25%) et des signes de decompensation cardiaque. Compte-tenu de la possibilit\ue9 de r\ue9cup\ue9ration, nous avons propos\ue9 \ue0 ce patient un RVA avec une bioproth\ue8se suivie de l'implantation d'un Impella pour soutenir l'h\ue9modynamique. La dur\ue9e de la CEC a \ue9t\ue9 de 67 minutes, dont 35 minutes de clampage aortique. En fait le sevrage de la CEC a \ue9t\ue9 suivi d\u2019une SBDP avec la n\ue9cessit\ue9 de doses importantes de m\ue9dicaments inotropiques (15\u3b3/Kg/min de dobutamine et 1 mg/h de nop\ue9pin\ue9phrine). L'implantation de l'Impella a \ue9t\ue9 effectu\ue9e par l'art\ue8re axillaire droite. Les conditions cliniques du patient pendant les 24 heures suivantes ont graduellement stabilis\ue9, permettant la r\ue9duction progressive de la dobutamine (8\u3b3/Kg/min) et la nop\ue9pin\ue9phrine (0.5 mg/h). Apr\ue8s 48 heures nous avons interrompu l'infusion de la nop\ue9pin\ue9phrine et avons r\ue9duit l'infusion de la dobutamine \ue0 5\u3b3/Kg/min. \uc0 J10, nous avons pu enlever l'Impella et l\u2019\ue9chographie trans\u153sophagienne a montr\ue9 un fonctionnement correct de la bioproth\ue8se. Dans les deux semaines suivantes nous avons commenc\ue9 un sevrage progressif de la dobutamine jusqu'\ue0 la suspendre \ue0 J23. Le patient a \ue9t\ue9 transf\ue9r\ue9 en r\ue9\ue9ducation \ue0 J35. En conclusion, l\u2019Impella peut \ueatre consid\ue9r\ue9 un outil valable pour le chirurgien cardiaque dans le traitement de la SBDP pour la simplicit\ue9 de l'implantation, de la gestion, du sevrage et de l\u2019ablation

Elective Impella Recover LP 5.0 utilization for postcardiotomy low-output syndrome after aortic valve replacement

Approximately 1% of patients undergoing cardiac surgery procedures develop postcardiotomy low-output syndrome (LOS). Impella Recover LP 5.0 (Abiomed, Danvers, MA) is a microaxial left ventricular assist device (LVAD) inserted retrograde into the left ventricle across the aortic valve. Here we report a case of aortic valve replacement with biological prosthesis in a patient with severe aortic regurgitation and impaired left ventricle systolic function, complicated by postcardiotomy LOS and successfully treated with a preoperative-planned use of Impella VAD. A 55-year-old male patient was admitted to our department with the diagnosis of severe aortic regurgitation and impairment of left ventricular function.Taking into account the possibility of recovery of this valvular pathology, it was decided to address the patient to an aortic valve replacement surgery followed by the implantation of an Impella LVAD to sustain the hemodynamic in the immediate perioperative and early postoperative period. In order to perform this operation and despite the patient's young age, we opted for a biological prosthesis. We utilized a 27mm Carpentier\u2013Edwards Perimount Magna Ease bioprosthesis (Edwards Lifesciences, Irvine, CA). The duration of cardiopulmonary bypass was 67 min with 35 min of aortic clamping. As expected, weaning from cardiopulmonary bypass was shortly followed by a postcardiotomy LOS with a progressive decline in medial arterial pressure, an increase of left atrial pressure (24 mmHg) and the necessity of increased inotropic support (15 \u3b3/kg/min of dobutamine and 1 mg/h of norepinephrine). The implantation of the Impella LVAD was performed through the right axillary artery. The clinical conditions of the patient during the next 24 h had gradually stabilized, allowing the progressive reduction of dobutamine (8 \u3b3/kg/min) and norepinephrine (0.5 mg/h). After 48 h we interrupted the infusion of norepinephrine and reduced dobutamine infusion at 5 \u3b3/kg/min. At postoperative day 10, we could remove the Impella LVAD and the ablation has been completed without any complication. During this procedure, the transesophageal echocardiogram showed an LVEF of 35% and an ITV of 13 supported by dobutamine 7 \u3b3/kg/min and proper functioning of the prosthetic valve. In the following 2 weeks we started a progressive weaning of dobutamine till to suspend it at postoperative day 23. The patient was discharged at postoperative day 35