Physical preconditioning on biventricular temporary mechanical circulatory support while awaiting heart transplantation

Abstract

Temporary mechanical circulatory support (tMCS) is increasingly used in patients with cardiogenic shock as a bridge to further treatment. We present the case of a 52-year-old female patient with biventricular heart failure who was bridged to heart transplantation employing biventricular tMCS through a non-femoral access. The ‘groin-free’ tMCS concept facilitates pre-habilitation while awaiting heart transplantation.

INTRODUCTION

Despite a remarkable development in devices providing temporary mechanical circulatory support (tMCS), cardiogenic shock (CS) in patients with acute or chronic heart failure is still associated with a high mortality [1]. tMCS including microaxial flow pumps (mAFP) is commonly used as a bridge to recovery or to a permanent device, whereas bridge to transplant (BTT) requires an anticipated waiting time.

We present a case of BTT on biventricular tMCS in a patient with CS (INTERMACS II) due to biventricular dilated cardiomyopathy. We aim to highlight the advantages of a ‘groin-free’ tMCS in facilitating mobilization and supporting recovery from end-organ failure.

CASE PRESENTATION

A 52-year-old female patient (66 kg, 160 cm) with a history of dilated cardiomyopathy was transferred to our hospital in CS on inotropic support, complicated by pneumonia-associated sepsis and acute on chronic renal failure. She suffered from chronic heart failure following myocarditis and had undergone dual-chamber ICD implantation due to ventricular tachycardia and cardiopulmonary resuscitation nine years prior. One year prior to her current admission, progressive heart failure led to recurrent hospitalizations, multiple ICD shocks, and an upgrade to CRT-D. Coronary artery disease was ruled out.

During the most recent hospitalization, weaning from inotropic support failed repeatedly and the patient met the listing criteria for high-urgency HTx. Predominant right-sided heart failure with severe tricuspid regurgitation in combination with ventricular arrhythmia precluded implantation of a permanent LVAD device. Upon admission, the NT-ProBNP level was elevated at 7484 pg/ml. Subsequently, the parameter experienced a fourfold increase over the course of two weeks of clinical deterioration. Eight days after listing the patient needed treatment with the ECMELLA 2.1 protocol. Right axillary access was used for both the arterial cannula and the mAFP and the right jugular vein was deployed for the venous cannula of the extracorporeal life support (ECLS) component (Fig. 1A) as previously described and according to our institutional protocol [2, 3]. End-organ recovery allowed a de-escalation strategy. The ECMELLA 2.1 was switched to a temporary right-ventricular assist device (tRVAD) with a double-lumen cannula via the right jugular vein (ProtekDuo, LivaNova, London, UK) (Fig. 1B), leaving the Impella 5.5 in place. Echocardiography revealed adequate unloading of the left ventricle, alongside notable improvement of the right ventricle and reduction in tricuspid regurgitation (Supplementary Material 1).

With the Impella delivering a flow of >5 l/min and the tRVAD providing over 3 l/min, successful weaning from mechanical ventilation and inotropic support was immediate, accompanied by a gradual recovery of renal function evidenced by decreasing creatinine levels without dialysis (Fig. 2). Following tMCS implantation and while maintaining antiarrhythmic drug therapy, there was a noticeable decrease in the frequency of arrhythmias.

A dedicated team of physiotherapists, intensive care nurses and perfusionists accompanied the patient’s gradual mobilization. Complete mobilization was achieved and by the fourth day after transitioning to ‘groin-free’ biventricular support the patient was ambulatory on the ward with assistance of the team (Video 1). Initially, the patient presented with a favourable nutritional status (BMI 25.5 kg/m²) and a normal serum albumin level. Frailty assessment for transplant evaluation, as indicated by the computed tomography (CT) scan findings, revealed a normal psoas muscle area index (Supplementary Material 2). The patient’s well-being and condition benefitted from the early start of oral feeding.

The patient experienced a peripheral neurological deficit of the right arm with paresthaesia and motor impairment (arm flexion with 3/5 power) due to the axillary access, which almost completely resolved during the further course. Orthotopic HTx was performed on day 19 after listing. A mild cellular rejection reaction (ISHLT 1R) in the myocardial biopsy resolved under adapted immunosuppressive therapy. We found mild non-donor-specific HLA antibodies (non-DSA) before and no DSA after transplantation (panel-reactive antibody 0%; blood group A negative). Echocardiography showed an adequate graft function on discharge.

DISCUSSION

For maximum systemic support, we opted for a ‘groin-free’ tMCS, combining ECLS for circulatory support and Impella 5.5 for left ventricular unloading via a single arterial access and jugular vein for venous drainage. The ECMELLA 2.1 approach provides better recovery conditions and enables de-escalation to left ventricular support alone in a majority of cases [4]. However, in case of biventricular failure, the transition to ‘groin-free’ biventricular support with a double-lumen cannula in combination with mAFP allows for oral nutrition, mobilization, and temporary renal recovery. Physical activity is essential for preventing muscle loss and hospital-associated deconditioning, which is demonstrated by the fact that a high level on the John Hopkins Mobility Scale is associated with better survival in CS patients on Impella [5]. Nevertheless, device-related complications should not be neglected and require close anticoagulation monitoring. Furthermore, treatment with mechanical circulatory support (MCS) poses a potential risk for allosensitization in pre-HTx patients, which may lead to prolonged waiting times and adversely affect prognosis. Notably, in our case, only mild non-DSA HLA I, that was negative on cytotoxicity testing, was observed following an elevated number of blood transfusions.

CONCLUSION

Temporary biventricular percutaneous support sparing femoral access is a feasible BTT strategy for critically ill patients. ‘Groin-free’ approaches provide both rapid haemodynamic improvement and preconditioning through advanced mobilization while preventing hospital-associated deconditioning.

SUPPLEMENTARY MATERIAL

Supplementary material is available at ICVTS online.

ACKNOWLEDGEMENTS

We thank Abiomed Inc. for the financial support to provide open access to the manuscript.

Conflict of interest: Anna Stegmann, Ruhi Yeter and Christoph Knosalla have nothing to declare. Pia Lanmüller receives payment or honoraria for lectures, presentations, speakers bureaus or educational events from Abiomed Inc.

DATA AVAILABILITY

All relevant data are within the manuscript and its Supporting Information files.

ETHICAL STATEMENT

The patient provided informed consent for the presentation of the case and visual material.

Reviewer information

Interdisciplinary CardioVascular and Thoracic Surgery thanks Manuel J. Antunes and the other anonymous reviewer for their contribution to the peer review process of this article.

REFERENCES