Impella 5.5 implantation in a patient with left ventricular assist device thrombosis as a bridge to recovery strategy

Impella 5.5 (Johnson & Johnson, U.S.A.) implantation is an established therapy to recompensate patients in cardiogenic shock and to bridge patients to decision for left ventricular assist device (LVAD) implantation as a proof-of-concept strategy.1, 2 Conversely, the device might also be used to strategically wean patients from LVAD to cardiac recovery as a bridge-to-decision concept. We present the case of a 61-year-old female who successfully underwent minimal-invasive HVAD (Medtronic, U.S.A.) implantation in 2013 due to dilated cardiomyopathy. In 2015, the patient suffered from acute VAD thrombosis and the pump was exchanged via lateral thoracotomy. The following course of the patient was uneventful and the patient refrained from being listed for cardiac transplantation. In 2023, she presented to our emergency department with elevated power consumption, low flow alarms of the VAD as well as hemolysis and hematuria. CT angiography and preoperative diagnostics revealed a recurrent severe pump thrombosis. Echocardiography showed a recovered left ventricular function with an LVEF of 40%–45% and no other cardiac impairments. Ramp testing and weaning from the VAD were no considerable therapeutic options due to a high risk of imminent heart failure and stroke due to pump thrombosis. To preserve the chance of cardiac recovery, the concept of functional LVAD occlusion and bridging the patient via Impella 5.5 implantation to recovery was indicated. Intraoperatively, a lateral thoracotomy was performed and the pump corpus and the outflow graft were exposed. LVAD decommissioning was completed via slow weaning of the pump and ligation of the outflow graft. Impella 5.5 placement was performed via the left subclavian artery and standard surgical technique. Postoperatively, the patient was extubated 3 h after surgery. Over the course of the next 6 days, Impella and catecholamine weaning was successfully performed under strict monitoring of hemodynamic and echocardiographic parameters (Figure 1). Early mobilization of the patient was achieved. The Impella was explanted in analgosedation on POD 6. On POD 8 the patient was discharged from intermediate care to normal ward. No postoperative complications occurred. After the implementation of heart failure medication regime, the patient was discharged home on POD 9 after the explantation of the device. Anticoagulation was presumed for 2 months after the procedure. Postoperative echocardiography revealed a left ventricular ejection fraction of >60% 3 months after VAD explantation. The patient remains under regular investigation in our heart failure clinic. Cardiac recovery after 10 years of LVAD support is rare. The usage of Impella 5.5 implantation is a feasible and safe concept to bridge LVAD patients to cardiac recovery and offers the possibility of LVAD re-implantation as a bailout option. Alternative concepts for decommissioning the device are the placement of a plug or full LVAD, interventional decommissioning, surgical explantation, and left ventricular reconstruction.3-5 We refrained from both due to the limited availability of the HVAD plug and to reduce surgical trauma and operating time as well as to avoid the use of the heart-lung machine. Thus, it needs to be noted that the patient remains at risk for internal device infection. We recommend consideration of this concept in patients with signs of cardiac recovery after LVAD implantation. Concept/design, drafting article, data collection: Jasmin S. Hanke. Data analysis/interpretation, critical revision of article, approval of article: All authors. Open Access funding enabled and organized by Projekt DEAL. No funding was received for this manuscript. JDS and GD are consultants for Abbott. BS is a consultant for Johnson & Johnson.