Impella as a bridge-to-closure in post-infarction ventricular septal defect: a case series.

Background: Post-infarction ventricular septal defect (PIVSD) is a rare, life-threatening complication of acute myocardial infarction (AMI). Few studies report the use of mechanical circulatory support (MCS) for the treatment of cardiogenic shock in this setting. We describe our experience using a microaxial, transvalvular device (Impella, Abiomed, Danvers, MA, USA) as a bridge-to-closure for PIVSD. Case summary: We identified 13 patients from two centres with cardiogenic shock due to PIVSD who received an Impella device between January 2016 and February 2022. Nine patients were transferred from another hospital, three with MCS devices [two intra-aortic balloon pumps (IABP), 1 Impella CP]. Eight patients received Impella 5.0, three received Impella 5.5 (one escalated from Impella CP), and two received Impella CP. The median time from AMI to Impella insertion was 5 (3-6) days. Five patients died on Impella support without an attempt to close the ventricular septum (VSD). Seven patients underwent successful VSD closure: six had surgical and one had percutaneous closure. One patient died during attempted percutaneous closure. Time from Impella insertion to VSD closure was 10.5 (7.8-14.0) days. Time from AMI to Impella was 5.0 (2.0-5.3) days in the group that survived to closure, and 6.0 (4.0-7.0) days in those who did not. Thirty-day mortality was 46%. Discussion: Support with Impella improved clinical stability in most patients, yet multi-system organ failure leading to death occurred in many patients. Patients who survived closure had earlier time from AMI to Impella, underscoring that prompt recognition of PIVSD and initiation of MCS may improve survival to surgical or percutaneous closure.

The Path of Least Resistance.

A 72-year-old patient presented S/P defibrillation for ventricular fibrillation cardiac arrest. We present an interesting teaching electrocardiogram that demonstrates alternating right and left bundle branch blocks, as well as an atrioventricular block that illustrates this patient's complex conduction system disease. (Level of Difficulty: Intermediate.).