Cardiology fellow THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON Houston, Texas, United States
Background: Restrictive physiology post- orthotropic heart transplant (OHT) is associated with poor survival and rejection needs to be ruled out. Treatment options are limited for a restrictive right ventricle (RV) after an OHT. In 2022, the FDA approved the Impella RP Flex to provide RV support for up to 14 days.
Methods: 53-year-old lady with a past medical history of Chagas cardiomyopathy s/p HeartMate 3 LVAD (10/14/2022), RV dysfunction, morbid obesity s/p gastric sleeve, underwent OHT on 7/27/2024. The intra-operative course was complicated by left lung injury due to adhesions requiring lingula resection, excessive bleeding s/p massive transfusion protocol, PEA arrest s/p central VA-ECMO cannulation for SCAI E cardiogenic shock (CS). VA-ECMO was decannulated on 7/31, and IABP was placed a few hours later for CS despite inotropy with epinephrine, with mixed venous oxygen saturation (SVO2) in the 40s. She had a severely restrictive RV although LVEF was normal on bedside echocardiography. On 8/3 SVO2 dropped to 30s with worsening end organ function so an Impella RP Flex was inserted via the right femoral vein. (Acute cellular rejection (ACR) and acute antibody-mediated rejection (AMR) had been ruled out by biopsy and DSA).
Outcome: There was a drastic hemodynamic improvement with the RV recovering some diastolic function after 2 weeks of rest due to the MCS. Impella RP Flex was slowly weaned by watching hemodynamics (including waveforms) and finally removed on 8/16 and ino-pressors were weaned off by 8/31. She got a tracheostomy on 8/16, was transferred to IMU on 9/13, and was discharged to inpatient rehab on 9/20.
Conclusion: Secondary graft dysfunction due to restrictive physiology post-OHT, with RV worse than LV, can be rescued with impella RP flex as it bypasses the RV and allows it to recover.
