Facilitated cardiac recovery in fulminant myocarditis: pediatric use of the Impella LP 5.0 pump

doi:10.1016/j.healun.2009.06.020

The Journal of Heart and Lung Transplantation

Volume 29, Issue 1, January 2010, Pages 96-97

https://doi.org/10.1016/j.healun.2009.06.020 Get rights and content

We describe the successful use of the Impella LP 5.0 intracardiac microaxial pump (Abiomed, Danvers, MA) in a 13-year-old boy with fulminant biopsy-proven viral myocarditis. The patient, who previously was in refractory cardiogenic shock despite increasing inotropic and vasopressor support, immediately stabilized after Impella LP 5.0 implantation and was successfully bridged to a full recovery. Months later, he remains completely well, with no intracardiac or peripheral vascular sequelae of the procedure. In carefully selected pediatric patients the Impella may be a beneficial form of temporary mechanical circulatory support for fulminant cardiogenic shock.

Section snippets

Case Report

A 13-year-old previously healthy boy presented to the provincial children's hospital with fulminant myocarditis after a recent viral illness. Despite mechanical ventilation and circulatory support with intravenous infusions of epinephrine, milrinone, and dobutamine, he continued to deteriorate over the subsequent 24 hours. Echocardiography performed 24 hours after admission demonstrated a decline in his left ventricular ejection fraction (LVEF) from 38% at admission to 12%. Given his size

Discussion

We describe the successful use of the Impella LP 5.0 intracardiac microaxial pump in a pediatric patient with fulminant myocarditis. Although promising evidence exists for the use of ventricular assist devices (VADs) in adults, extracorporeal membrane oxygenation (ECMO) and centrifugal pump-based assist devices remain the most common form of mechanical support for pediatric cardiac patients, despite significant hemorrhagic and neurologic complications.1, 2

The Impella is a minimally invasive,

Disclosure statement

The authors wish to acknowledge Dr. Robert Moss and Dr Lynn Straatman for their guidance in the preparation of this manuscript.

None of the authors reports a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript, or other financial interests, funding sources, relevant disclosures, or other potential conflicts of interest.

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There are more references available in the full text version of this article.

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The Impella 5.5 has been successfully used in the adult population; however, safety and efficacy data in patients aged less than 18 years are limited.
Six pediatric patients, aged 13 to 16 years and weighing 45 to 113 kg, underwent axillary artery graft placement and attempted placement of the Impella 5.5 device at our institution between August 2020 and March 2023.
Indications for implantation were heart failure secondary to myocarditis (2), rejection of prior orthotopic heart transplant, idiopathic dilated cardiomyopathy (2), and heart failure after transposition of the great arteries repair. Placement was unsuccessful in a 13.8-year-old female patient due to prohibitively acute angulation of the right subclavian artery, and venoarterial extracorporeal membrane oxygenation cannulation was performed via the axillary graft. In 5 patients with successful Impella 5.5 placement, median duration of support was 13.5 days (range, 7-42 days). One experienced cardiac arrest secondary to coagulation-associated device failure, requiring temporary HeartMate3 implantation. Four patients were bridged to transplant; 3 patients received a transplant directly from Impella 5.5, and 1 patient received a transplant after HeartMate3. The final patient received the HeartMate3 on Impella day 42 and is awaiting transplant.
Although exact size cutoffs and anatomy are still being determined, our experience provides a framework for use of the Impella 5.5 in adolescents.
Short-Term Mechanical Cardiopulmonary Support Devices
2018, Heart Failure in the Child and Young Adult: From Bench to Bedside
The advent of successful mechanical cardiopulmonary support in children has ushered in profound changes in the management of pediatric heart failure over the past 15 years. While attention has often been focused on the Berlin Heart EXCOR (which remains the only device specifically approved for use in children) (Fraser et al., 2012), improvements in short-term devices have also had a dramatic impact. Historically, extracorporeal membrane oxygenation (ECMO) provided the only option for mechanical support in children with heart failure. While the ability to provide full cardiopulmonary support continues to make ECMO a viable option for temporary support, an increasing number of ventricular assist devices are now available in sizes appropriate for many children. A thorough understanding of the devices available, their indications and contraindications, and technical nuances is critical to successful outcomes when managing children with heart failure refractory to medical management.
Short-Term Mechanical Cardiopulmonary Support Devices
2017, Heart Failure in the Child and Young Adult: From Bench to Bedside
The advent of successful mechanical cardiopulmonary support in children has ushered in profound changes in the management of pediatric heart failure over the past 15 years. While attention has often been focused on the Berlin Heart EXCOR (which remains the only device specifically approved for use in children) (Fraser et al., 2012), improvements in short-term devices have also had a dramatic impact. Historically, extracorporeal membrane oxygenation (ECMO) provided the only option for mechanical support in children with heart failure. While the ability to provide full cardiopulmonary support continues to make ECMO a viable option for temporary support, an increasing number of ventricular assist devices are now available in sizes appropriate for many children. A thorough understanding of the devices available, their indications and contraindications, and technical nuances is critical to successful outcomes when managing children with heart failure refractory to medical management.
Diagnosis and treatment strategies for children with myocarditis
2016, Progress in Pediatric Cardiology
Citation Excerpt :
A small centrifugal pump can deliver 5 to 8 L/min of flow and allows for full ambulatory support. The Impella® device has also been applied as bridge to recovery in patients with myocarditis [57–60]. Like the TandemHeart®, the Impella® is a percutaneous device that is intended for temporary circulatory support.
2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology - Association Canadienne de Cardiologie d'intervention)
2015, Journal of Cardiac Failure
Citation Excerpt :
At this time, the only percutaneous device approved in the United States for short-term cardiac support in children is the IABP, with all other modalities requiring surgical implantation. MCSs have been utilized for circulatory support in older children successfully in their current configuration.40,41 An important limitation in this patient population is femoral vessel size.
Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella^®; left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.
2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia intervencion; Affirmation of value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention
2015, Journal of the American College of Cardiology
Citation Excerpt :
At this time, the only percutaneous device approved in the United States for short-term cardiac support in children is the IABP, with all other modalities requiring surgical implantation. MCSs have been utilized for circulatory support in older children successfully in their current configuration (40,41). An important limitation in this patient population is femoral vessel size.
Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella^®; left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

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Percutaneous mechanical supportFacilitated cardiac recovery in fulminant myocarditis: pediatric use of the Impella LP 5.0 pump

Section snippets

Case Report

Discussion

Disclosure statement

Technology insight: use of ventricular assist devices in children

Nat Clin Pract Cardiovasc Med

Extracorporeal Life Support Registry Report 2004

ASAIO J

Percutaneous mechanical support
Facilitated cardiac recovery in fulminant myocarditis: pediatric use of the Impella LP 5.0 pump