Recently, the effectiveness of the Impella device in stabilizing hemodynamics during the perioperative period of postinfarction VSR has been reported [2]. Preoperatively, the Impella device contributes to hemodynamic stabilization, recovery of cardiac muscle from myocardial infarction, and improvement of local myocardial tissue quality. In addition to these effects, its postoperative use is considered beneficial for decreasing the risk of residual leakage of a VSR by LV unloading. The Impella 5.5 is designed to generate more flow and can be used for longer period compared to one of its former models such as Impella CP. We used a single Impella 5.5 device for 28 consecutive days, which is, to our knowledge, the longest period of use for a postinfarction VSR patient among the previously published reports, and is the first report on the LV perforation by the device [3,4,5,6,7,8,9,10].

Preoperatively, whether Impella alone is adequate enough for hemodynamic stabilization depends on the presence or absence of right heart failure. If right heart failure occurs, Impella alone may not work effectively without adequate left ventricular preload. In the present case, right heart failure gradually developed after 10th admission day as the left to right shunt increased due to the VSR becoming larger over time, eventually leading to significant tricuspid regurgitation. In this setting, ECPELLA (extracorporeal membrane oxygenation + Impella) may be effective for hemodynamic support [11]. However, we did not use ECPELLA as it was time for surgery after 16 days of Impella support for myocardial tissue maturation.

During surgery, the shaft of the Impella is clampable along with aortic cross-clamping, allowing for the use of a single device without the need for replacement throughout the perioperative period. In this setting, we usually use epiaortic echocardiography to check the position of a device and not to clamp the motor housing. The Impella 5.5 has a shorter length compared to previous models, which may theoretically reduce the likelihood of the need for aortic cross-clamping too high on the ascending aorta. This device, however, lacks a soft and flexible pigtail part at its end; thus, the stiff inlet part of the device could come into direct contact with the LV wall, which carries a possible risk of free wall rupture as occurred in the present case. One should be cautious especially in cases where an arrested and flaccid heart needs to be lifted. One of the countermeasures to avoid this complication might be to pull out the device so that a minimum of approximately 5 cm of the device is left in the LV, in accordance with the manufacturer’s guidance. Additionally, the aortic cross-clamp should be applied under epiaortic echo guidance not to clamp the motor housing of the device. In the present case, we cross-clamped the aorta as high as possible because epiaortic echo was not available during this repeat aortic cross-clamp. This issue may not be true in beating heart surgeries where the Impella 5.5 tip is not likely to contact the LV wall, or in cases with the previous Impella devices with a pigtail end.

If a single Impella device is used for a prolonged perioperative period, there is a potential risk of thrombus formation as seen in the present case. An organized thrombus was attached to the outlet portion of the Impella device, but fortunately the patient had no thromboembolic events. According to recent review literature, complications associated with long-term use of the Impella device included bleeding, stroke, and device malfunctions, with the duration of support ranged from 9.8 to 70 days. However, the complication observed in the present case was not reported [12]. The importance of balancing bleeding and thromboembolic risks, and maintaining optimal anticoagulation early after surgery is highlighted.