nowadays cardiac surgeons must face the problem of severely impaired left ventricle function almost on a daily basis . heart transplantation , due to the limited donor pool , can be offered only to a small number of patients suffering from cardiac failure [ 1 , 2 ] . furthermore , the idea of long - term mechanical support as a destination therapy is still evolving . hence , efforts to optimize the results of routine cardiac surgery have to be undertaken . in a properly selected group of patients coronary surgery alone or combined with mitral surgery can improve both quality of life and long - term survival . with borderline ventricular function prior to surgery this may result in failed weaning from cardiopulmonary bypass . in isolated coronary surgery beating heart strategy , either on or off pump seems to be a safer option . its use however is hardly possible when mitral valve repair or replacement needs to be done . intra - aortic balloon pump ( iabp ) is a gold standard here , but some patients may require more sophisticated mechanical assistance [ 3 , 4 ] . the idea of short - term , perioperative mechanical support , preferably with a low anticoagulation regime , looks very convenient in this respect . impella microaxial pumps ( abiomed europe gmbh , aachen , germany ) seem to meet these criteria . they use the idea of pulling the blood from the left ventricle into the aorta , which is accomplished by means of a rotating impeller positioned in the aorta with the tip of the device and inlet area positioned in the left ventricle . this results in reduction of both left ventricle end diastolic volume ( lvedv ) and left ventricle end diastolic pressure ( lvedp ) . the systemic pressure and flow are increased . the less stretched left ventricle , with better subendocardial perfusion , has more time to recover . on the other hand , the impella pump can be applied either by cardiologists ( impella 2.5/impella cp ) in a cath lab setting or by cardiac surgeons ( impella 5.0/impella ld ) in an operating theatre with either peripheral vascular or central direct access . offering flow up to 5 l / min , the anticoagulation management requires only heparin infusion to keep activated clotting time ( act ) not shorter than 160 s. thanks to the automated controller with an intuitive , user friendly interface , operating the device can be easily mastered by doctors and nursing staff . a 64-year - old woman suffering from ischemic dilated cardiomyopathy associated with mitral insufficiency was referred for combined treatment consisting of resynchronisation therapy followed by simultaneous coronary and mitral surgery . initial echocardiography revealed impaired global contractility ( ejection fraction [ ef ] 10 - 15% ) , dilated left ventricle ( left ventricle end diastolic diameter [ lvedd ] 7.8 cm ) , significant ventricular asynchrony ( 50 ms ) and moderate mitral regurgitation ( vena contracta [ vc ] 6 mm ) due to both restriction of the posterior leaflet and dilation of the mitral annulus ( 5.5 cm ) . there were no significant abnormalities regarding the right ventricle , pulmonary valve and tricuspid valve . clinically the patient presented with end stage cardiac failure including resting dyspnea ( nyha iv ) . the patient underwent uneventful implantation of an icd crd ( maximo ii ) , which resulted in improved exercise tolerance . this was consistent with post - procedure echocardiography showing no significant ventricular asynchrony ( 4 ms ) , slightly improved contractility ( ef 20% ) and unchanged moderate mitral regurgitation ( vc 6 mm ) . therefore the patient was referred for combined cardiac surgery including mitral repair and coronary grafting . because of poor lv function and the complexity of the procedure , it was decided to apply short - term mechanical support during and after surgery . the impella ld microaxial pump was chosen due to the simplicity of implantation and the low anticoagulation regime . also , the impella ld does not require a hybrid theater with fluoroscopic guidance . antegrade cold blood cardioplegic solution was administered through the aortic root . the posterior descending artery ( pda ) and left anterior descending artery ( lad ) were grafted with the long saphenous vein and left internal thoracic artery respectively . the left atrium was entered in a routine manner after dissecting sondergaard 's plane . on inspection the echocardiographic findings were confirmed . the only surgical issue was severe atherosclerosis of the ascending aorta affecting both anastomosis of the vein graft and implantation of the impella device . before the implantation a 10 mm dacron graft was anastomosed to the ascending aorta using a side biting clamp ( fig . the impella catheter was inserted through the graft and then , under transesophageal echocardiographic ( tee ) guidance , was forwarded through the ascending aorta and the aortic valve into the left ventricle ( figs . 2 and 3 ) . immediately after confirming the position the impeller rotation was initialized . meticulous attention was paid to maintain proper left ventricle volume preloading in order to avoid pump malfunction . after securing hemostasis the chest was closed , letting the driveline out above the suprasternal notch and through the upper end of the sternotomy wound . the patient was transferred to intensive treatment unit ( itu ) in a stable condition . there she was kept sedated and ventilated electively . therapeutic activated clotting time ( act ) the position of the pump was checked daily and in case of any suspicion of malfunction . adequate flow was maintained most of the time , with one episode of stopping of the machine , which was easily managed with fluid infusion . the inotropic support was reduced gradually without affecting hemodynamic stability . on the 2 postoperative day the further postoperative course was mainly uneventful , although prolonged mechanical ventilation was required ( 8 days ) . the first follow - up visit two months after discharge confirmed good exercise tolerance and satisfactory echocardiographic findings ( trace mitral regurgitation , lvedd 7.6 cm , ef 25% ) . impella device inserted through the tubing graft anastomosed to the ascending aorta impella device in the ascending aorta , approaching the aortic valve impella device finally positioned in the left ventricle doppler scan showing the flow from the left atrium to the left ventricle ( blue ) and within the device from the left ventricle to the aorta ( red ) patients with impaired left ventricle function require a particular surgical strategy . obviously , it is crucial to perform a routine procedure such as coronary grafting or valve surgery with meticulous surgical technique and good timing . therefore , these patients should be operated on by senior surgeons . however , even in experienced hands , such cases may prove quite tricky . sometimes , even perfect coronary anastomoses and the shortest ischemic time can not prevent failed weaning from cardiopulmonary bypass . the possibility of perioperative mechanical support , exceeding the intra - aortic balloon pump , is quite tempting . one option is extracorporeal membrane oxygenation ( ecmo ) , which can support the circulation for up to a few weeks . this requires , however , both arterial and venous cannulation , an aggressive anticoagulation regime and specially trained perfusionists and nursing staff . extracorporeal membrane oxygenation is also associated with a long list of potential complications including infection , bleeding , thromboembolic events , hemolysis and finally multiorgan failure ( mof ) . there is no doubt that ecmo is a well - established and recognized life - saving procedure ; however , the question may be raised whether some patients could benefit from an easier technology used in a planned manner . , there is quite a wide range of indications for their use , two in cardiology : as a rescue treatment in cardiogenic shock caused mainly by acute coronary syndrome   and , electively , as a support in high - risk percutaneous interventions including pci and vt ablation [ 7 , 8 ] . because of endovascular insertion and therefore limited device size ( 12 fr ) the generated flow can not be higher than 2.5 l / min , which usually is enough in the above situations . impella pumps may be applied in post - cardiotomy shock when an intra - aortic balloon is not enough to succeed in weaning from cardiopulmonary bypass . cardiac surgeons may also use them more electively as a perioperative support in patients with significantly impaired left ventricular function . the surgical insertion can be performed either peripherally ( impella 5.0 ) or directly through the ascending aorta ( impella ld ) . in peripheral access the femoral or axillary artery is exposed , then the device is inserted using a tubing graft and forwarded to the left ventricle under fluoroscopic guidance . the hybrid theatre setting is required , but on the other hand it is possible to perform less invasive , thoracoscopic surgery . in direct access , after sternotomy , the implantation is quite easy under tee guidance . whatever the access , the surgical technique allows one to insert a bigger device ( 21 fr ) , which is able to generate flow up to 5 l / min ( ! ) . that means that after the procedure , which is slightly more complex than insertion of an iabp , and having a device which is almost as easy to operate as an iabp , we achieve an effect that is very close to the benefit of left ventricular assist device ( lvad ) . the aforementioned problem of left ventricle venting is solved by definition , with impella being an intraventricular device . it should not stay in for longer than 5 days , which is more than enough to rethink and rearrange a new strategy . ( impella , ecmo , lvad , recovery or transplant ) . when it is applied electively , as in our case , the chances are very high that only the first stage will be necessary . this being the case , the impella pump can be deservedly regarded as a  short bridge to recovery  .
cardiac surgeons have to face the problem of impaired left ventricle function in patients undergoing routine valve or coronary procedures . 
 the intra - aortic balloon pump is not always effective in preventing cardiac failure . 
 the idea of using a microaxial rotating pump as a short - term perioperative support seems to be a convenient solution . 
 the case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the impella ld pump is presented . 
 various options of applying the impella device are discussed , especially as a bridge to transplant or bridge to recovery .