Ramya Deepthi Billa, MBBS
University of Iowa Stead Family Children's Hospital
Iowa City, IA
Disclosure information not submitted.
Niranjan Vijayakumar, MD
Boston Children's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Heather Elmore, ARNP
Nurse Practitioner, Pediatric Critical Care
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Aditya Badheka, MD, MS
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospital and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Madhuradhar Chegondi, MD
Clinical Associate Professor, Division of Pediatric Critical Care Medicine
University of Iowa Stead Family Childrens's Hospital
Iowa City, IA, United States
Disclosure information not submitted.
Title: Use of Impella 5.5 in a Pediatric Patient with Cardiogenic Shock Secondary to Viral Myocarditis
Introduction: Left ventricular assist devices (LVAD) support circulation in patients with failing left ventricle. Impella® device is a percutaneously placed LVAD intended for short-term use and is primarily used in adults. Impella 2.5 and 5.0 devices have been used in pediatric patients. However, the larger Impella® 5.5 with peak blood flows up to 6 L/min has not been reported in children. We present a teenager with cardiogenic shock secondary to viral myocarditis, supported with Impella® 5.5 and an implantable VAD as a bridge to successful heart transplantation.
Description: A 13-year-old, 46 kg (BSA 1.5 m2) previously healthy boy with a 4-day history of cough and dyspnea was transferred to our pediatric ICU due to cardiac arrest at an outside institution. Admission workup was positive for Coronavirus OC43. Echocardiogram on admission showed severe LV dysfunction with a 20% ejection fraction (EF), possibly due to myocarditis. Despite maximal medical therapy, LV dysfunction worsened with EF of 7%. After a multi-disciplinary discussion, he was placed on the Impella CP device on hospital day (HD) 1 to unload the LV in hopes of potential recovery. The device provided flows around 3.8 L/min (Cardiac Index, CI 2.5 L/min/m2). Although he had a good recovery initially, he progressed to severe pulmonary edema. The Impella CP device was upsized with Impella 5.5 providing flows ~5.3 L/min (CI 3.5 L/min/m2) on HD 5 to augment LV unloading. He underwent cardiac catheterization for persistent pulmonary edema, which showed increased pulmonary capillary wedge pressure of 37 mmHg, and RV end-diastolic pressure of 16 mmHg. Due to persistent severe left atrial hypertension, on HD 14, he was placed on Veno-Arterial ECMO, had an atrial septostomy, and Impella device removal. He had Heartware LVAD, CentriMag RVAD placement with ECMO decannulation on HD 19, and RVAD removal on HD 29. He underwent orthotopic heart transplantation 4 months after his initial presentation without complications and showed good recovery.
Discussion: Impella 5.5 can be used in appropriate size children with severe LV dysfunction. However, the device may not be sufficient to relieve severe LA hypertension in patients with severe LV dysfunction. Additional bi-ventricular support may be needed for successful bridging to recovery or transplant.