Background

A 60-year-old male with end-stage heart failure was undergoing cardiac transplant workup at our facility. Conservative methods of weight loss had failed to lower his BMI from 41 and he was recommended for bariatric surgery. His severe LV dysfunction with reduced ejection fraction of 20-25% along with non-re-vascularizable CAD resulting in Canadian class IV angina placed him at high risk for peri-operative complications. Proactive placement of temporary MCS support was proposed as a bridge to bariatric surgery to minimize oxygen demand of the myocardium during general anesthesia and to support any potential hemodynamic and arrhythmic complications. The patient agreed with the plan after the risks and benefits were extensively discussed. His volume status was optimized as outpatient. He was admitted to the hospital for placement of Impella-CP and Swan-Ganz hemodynamic catheter and underwent sleeve gastrectomy the following day. As clinically suspected, the patient did develop hypotension during anesthesia induction and had multiple non-sustained ventricular arrhythmias requiring intravenous amiodarone and lidocaine administration. After successful completion of the procedure, the Impella was maintained for 36 hours post-operatively without anticoagulation before removal. There were no post-operative complications, and the patient was discharged 4 days later. DiscussionTemporary mechanical circulatory support devices (MCS) are widely used for hemodynamic support during cardiac procedures such as high-risk coronary intervention or ablative therapy for tachyarrhythmias. Their use during non-cardiac procedures, however, has not been documented. The case above describes the first successful use of an Impella device to support a patient undergoing sleeve gastrectomy.