Use of the Impella 5.0 as a bridge from ECMO to implantation of the HeartMate II left ventricular assist device in a pediatric patient

A 10-yr-old previously healthy boy presented in cardiogenic shock after collapsing at school was subsequently diagnosed with a dilated cardiomyopathy at an outside hospital. Within hours following transfer to our cardiovascular intensive care unit (CVICU), the patient quickly decompensated, necessitating emergent V-A ECMO cannulation. Social service issues initially precluded listing for cardiac transplantation. On hospital day no. 14, an Impella 5.0 device was surgically implanted via the right femoral artery leading to successful weaning from ECMO (Fig. 1). The Impella required replacement 10 days after implantation because of mechanical failure. On hospital day no. 27, the Impella was removed and a HeartMate II LVAD was implanted for long-term management (Fig. 2). The procedure was complicated by pericardial tamponade requiring emergent chest exploration and evacuation of a large pericardial hematoma. The patient was extubated on hospital day no. 56 and weaned off all inotropic infusions. Demonstrating consistently appropriate hemodynamics, the patient was discharged from the CVICU to the acute care floor, and on hospital day no. 139, the patient was transferred to another institution closer to his father’s home for continuing care. After further rehabilitation, the patient was listed for and subsequently underwent successful cardiac transplantation. The Impella 5.0 is seen in long axis on transesophageal echocardiogram. The HeartMate II (LV apical cannula) is seen in four-chamber view on transthoracic echocardiogram. Ventricular assist devices are used with increasing frequency in children for the treatment of cardiogenic shock (INTERMACS indication 1) or progressive decline, while on inotropic support (INTERMACS indication 2) (1). A recent report of 99 patients in the Pediatric Heart Transplant Study database reported 77% patients surviving to transplantation and 5% being successfully weaned from support (2). Ventricular assist devices are considered in several circumstances: implantation for temporary support as a bridge to cardiac transplantation or permanent implantation as “destination therapy” for those who are not expected to proceed with transplantation. A third indication for VAD implantation, “bridge to candidacy,” has received consideration for patients who are not currently candidates for transplantation, but who may qualify for listing in the future. Ventricular assist devices that are most commonly used in children are not amenable to outpatient or long-term use. A recent report suggests a significant risk for infection and major bleeding events, often within 14 days of implantation (3). Furthermore, although strategies to wean children from the Berlin Heart or Thoratec PVAD have been published, the success rate is low, and the placement of a ventricular assist device often is viewed as a commitment to moving toward transplantation. In situations where transplantation may not be an option, the placement of one of these devices may also not be appropriate. The placement of a removable Impella 5.0, however, allowed the child to be weaned from ECMO and provided ample time to secure a stable home environment, before committing the patient to a permanent device. Use of the Impella 5.0 in the adult population as a short-term bridge to long-term mechanical support has been described; however, there is little published on the use of the Impella 5.0 in a pediatric patient (4, 5). Nevertheless, for selected pediatric patients who require time to develop the most appropriate care pathway beyond the capabilities of ECMO, the Impella may provide a few weeks of temporary mechanical support, beyond which fully implantable assist devices capable of serving either as a bridge to transplantation or as destination therapy may be the best option.