Fluoroscopy-free Impella repositioning after coronary artery bypass grafting: case report of a novel echocardiographic-guided technique.

BACKGROUND

Cardiogenic shock (CS) complicates 5-10% of myocardial infarctions and is a major cause of morbidity and mortality. Temporary mechanical circulatory support (MCS), such as the Impella CP device, has become crucial for stabilizing patients with severe left ventricular dysfunction. However, device positioning remains challenging, particularly when complications arise, such as the need for repositioning or replacement. This case report presents an innovative approach to fluoroscopy-free Impella repositioning using transesophageal echocardiography (TEE) guidance, which has not been previously documented in the context of coronary artery bypass grafting (CABG) and mitral valve surgery.

CASE DESCRIPTION: A 55-year-old male with severe left ventricular dysfunction and a history of diabetes and dyslipidemia was admitted with acute chest pain. Coronary angiography revealed severe three-vessel disease. After initial stabilization with an intra-aortic balloon pump (IABP), an Impella CP device was deployed for additional hemodynamic support. The patient then underwent CABG with five grafts and mitral valve repair via a median sternotomy. Before the CABG, the Impella device was temporarily positioned in the descending aorta to allow clamping of the ascending aorta during surgery. After the procedure, the Impella device was repositioned from the descending aorta to the left ventricle (LV) under TEE guidance. Manual pressure was applied externally by the surgeon to facilitate the pigtail catheter's passage through the valve. Once the device entered the LV, its final position was confirmed with TEE in both long-axis and short-axis views, ensuring optimal placement in the left ventricular cavity.

CONCLUSIONS

This case demonstrates the feasibility and safety of performing Impella repositioning without fluoroscopy. By utilizing echocardiography for device guidance, the approach reduces the risk of vascular injury and eliminates the need for additional large-bore arterial access. This method represents a novel strategy for improving the management of patients with severe left ventricular dysfunction post-surgery.