INTENSIVIST Inspira Health Collingswood, NJ, United States
Introduction: The combination of ProtekDuo and Impella, known as Propella, is a novel approach to bi-ventricular support. Patients with left ventricular assist device (LVAD) support can develop right ventricular (RV) failure due to increased preload, pre-existing RV dysfunction, altered ventricular interdependence, and septal shift. As percutaneous LV support devices are used more for myocardial infarction (MI)-related cardiogenic shock, RV failure can occur leading to early mortality. We present three cases illustrating how excessive blood transfusion can precipitate RV failure and hypoxia ultimately benefiting from Propella support.
Description: A 57-year-old male with end-stage renal disease and heart failure with severely reduced ejection fraction (HFsrEF) had recurrent ventricular tachycardia. After cardiac catheterization and triple-vessel coronary artery bypass graft (CABGx3) with Impella 5.5 placement, he had increasing bloody chest tube output with shock requiring multiple blood products. Another 57-year-old male had two episodes of ventricular fibrillation-mediated cardiac arrest. After percutaneous coronary intervention with a drug-eluting stent and intra-aortic balloon pump (IABP), he suffered hemorrhagic shock, required chest tube drainage and numerous blood transfusions. A 78-year-old male with ischemic HFsrEF underwent optimization with milrinone and diuresis before CABGx3 with Impella 5.5 insertion. He also had large volume bloody chest tube output needing multiple transfusions. All patients developed refractory hypoxemia and RV dysfunction requiring ProtekDuo placement. The second case had IABP exchange for Impella CP to match flow rates. With Propella support, all three eventually stabilized on minimal circulatory support, were decannulated, and discharged.
Discussion: These cases highlight the role of Propella in managing MI-related cardiogenic shock complicated by bleeding and RV failure. The timely use of bi-ventricular support was pivotal in stabilizing deteriorating patients. Vigilant monitoring with an anticipatory approach in deploying bi-ventricular support could be critical for high-risk patients. Future research should refine predictive models for RV failure, such as increasing LV mechanical support, and help reduce RV-related morbidity post-LV support device implantation.
