Impella 5.5-supported coronary artery bypass grafting in severe left ventricular dysfunction

Surgical revascularization carries a class I recommendation for the treatment of ischaemic cardiomyopathy and multivessel coronary artery disease, yet coronary artery bypass grafting carries substantial risk of postoperative low cardiac output syndrome and subsequent mortality in patients with severe left ventricular systolic dysfunction. Off-pump coronary artery bypass grafting avoids cardiopulmonary bypass and cardioplegic arrest, but may not be feasible in severe left ventricular systolic dysfunction because of intraoperative haemodynamic instability and impaired exposure of the dilated heart. Pre-emptive mechanical circulatory support may resolve these tensions. This video tutorial presents the Impella 5.5-supported coronary artery bypass procedure, as an application of the 'protected cardiac surgery' concept. During this procedure, a surgically implanted microaxial flow pump (Impella 5.5) enables complete off-pump revascularization. Patient selection, preoperative planning and the step-by-step procedure are detailed, and illustrated by a patient with an ejection fraction of 19%, severe left ventricular dilatation, viable myocardium and three-vessel disease. The Impella 5.5-supported coronary artery bypass procedure was performed successfully, with planned postoperative support maintained, and eventual awake explantation. Consequently, this video tutorial demonstrates the feasibility and reproducibility of the Impella 5.5-supported coronary artery bypass procedure, allowing the conduct of future prospective comparative studies to define its eventual role, and to establish how pre-emptive support may improve outcomes.