Temporary Left Ventricular Unloading With Impella as a Bridge to Emergency Surgery for Acute Mitral Bioprosthetic Failure

Figures

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  Figure 1. Serial chest radiographs from baseline to late follow-up (A) Baseline film obtained 3.5 months before admission, showing clear lung fields with the mitral prosthesis and the tricuspid annuloplasty ring. (B) Film obtained on arrival in the emergency department, showing near-complete opacification of both lung fields with loss of the cardiac silhouette. (C) After tracheal intubation. (D) Shortly before insertion of the Impella CP; the pulmonary artery catheter is in place. The image was cropped above the shoulders so that a positioning annotation lay outside the frame. (E) Film obtained at the end of the operation, showing a marked increase in aeration. (F) Day 73, in the outpatient clinic: the lung fields are clear, and the right hemidiaphragm remains elevated (arrowhead), indicating the right phrenic nerve palsy, which was not apparent while the patient was ventilated. (A) and (F) were obtained with the patient standing, and (B)-(E) with the patient supine, so diaphragmatic position cannot be compared directly across all panels These are clinical images exported from the original imaging data, to which panel letters and an arrowhead are added, marking regions of interest. Nothing…

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  Figure 2. Serial computed tomography of the chest (lung window) Matched axial sections at two levels in every study: (Left) the middle of the fourth thoracic vertebra and (Right) the middle of the seventh thoracic vertebra. (A) 3.5 months before admission: well-aerated lung fields. (B) Day 0, shortly after intubation: diffuse bilateral ground-glass opacity with dependent consolidation and bilateral pleural effusions (red circles). (C) Day 3: markedly improved compared with (B), with only residual dependent consolidation and small pleural effusions (red circles). (D) Day 28: near-complete resolution, with residual right lower lobe atelectasis (yellow circle) and slight residual consolidation in each lung (red circles) These are clinical images exported from the original imaging data, to which panel letters and circles are added, marking regions of interest. Nothing in the figure is obscured or reconstructed, and no part of any image has been filled in or interpolated. The image was not generated or altered by generative artificial intelligence

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  Figure 3. Time course of oxygenation and hemodynamics (A) From admission to the intensive care unit until approximately 29 hours after arrival, shown as four stacked panels with a common time axis: systemic arterial pressure; mean pulmonary artery pressure with the PaO₂/FiO₂ ratio; the fraction of inspired oxygen with mixed venous oxygen saturation; and arterial lactate with the cardiac index. The horizontal bracket marks the interval of Impella CP support, and the wavy break marks the operation, during which intensive care unit measurements are not available. (B) Days 0-12, showing the PaO₂/FiO₂ ratio and the fraction of inspired oxygen; the shaded band marks the period after extubation. Shaded ribbons in both panels represent inhaled nitric oxide and are schematic, with the dose annotated in ppm PaO₂: partial pressure of oxygen; FiO₂: fraction of inspired oxygen; iNO: inhaled nitric oxide; SvO₂: mixed venous oxygen saturation; CHDF: continuous hemodiafiltration; PA: pulmonary artery; P/F: partial pressure of oxygen/fraction of inspired oxygen This image was created by the authors from the patient’s clinical record using Python 3 (Python Software Foundation, San Francisco, CA) with the…

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  Figure 4. Mechanism of acute bioprosthetic valve failure (A) Intraoperative transesophageal echocardiography, mid-esophageal long-axis view. A prosthetic leaflet has detached and prolapsed into the left atrium (yellow arrowhead). (B) A comparable long-axis view with color Doppler. (C) Mid-esophageal commissural view with color Doppler. Yellow arrows in (A)-(C) indicate the Impella CP catheter within the left ventricle. (D) The explanted bioprosthesis viewed from the ventricular side; the white arrows indicate the stent post and the site of the tear. Brightness and contrast were adjusted uniformly across the whole photograph Ao: aorta; LA: left atrium; LV: left ventricle Images A-C are clinical images exported from the original imaging data; image D is a photograph of the explanted bioprosthesis. Panel letters, arrows, and an arrowhead are added, marking regions of interest. Nothing in the figure is obscured or reconstructed, and no part of any image has been filled in or interpolated. The image was not generated or altered by generative artificial intelligence

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  Figure 5. Postoperative course (Upper panel) Serial estimated glomerular filtration rate, calculated by the laboratory from the measured serum creatinine concentration. The shaded band marks continuous hemodiafiltration, during which values are not shown. (Lower panel) Events by organ system. On the respiratory row, each mode of delivery is shown in its own shade; the tapering band represents inhaled nitric oxide, weaned over the first postoperative week. On the rhythm row, the darker bars indicate atrial fibrillation and the paler bars indicate ventricular pacing; the remaining periods are sinus rhythm. On the imaging row, the circles are open for CT, filled for echocardiography, and gray for catheterization; on the neurologic row, they are filled for the infarcts and open for the phrenic nerve palsy. Vertical dashed lines mark extubation, discharge from the intensive care unit, discharge home, and cessation of warfarin. The horizontal axis is broken between days 31 and 45, and the right-hand segment is compressed AF: atrial fibrillation; CHDF: continuous hemodiafiltration; CT: computed tomography; eGFR: estimated glomerular filtration rate; HFNC: high-flow nasal cannula; iNO: inhaled…

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  Figure 6. Transthoracic echocardiography on day 16 (A) Apical four-chamber view. (B) The same view in systole with color Doppler. No appreciable regurgitant jet is seen at the mitral prosthesis LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle Two machine-generated overlays in the black margin and the portion of the electrocardiographic trace intruding into the cropped field were painted out; neither lies in a diagnostically relevant region. These are clinical images exported from the original imaging data, to which panel letters are added. Nothing else in the figure is obscured or reconstructed, and no part of any image has been filled in or interpolated. The image was not generated or altered by generative artificial intelligence