Desai, Aarti

The Impella 5.5 is an axillary mechanical circulatory support device used in patients with cardiogenic shock, but those with small left ventricular (LV) cavities may be at risk for suction events, hemolysis, malpositioning, hypoperfusion, and LV injury. Informally accepted guidelines, extrapolated from durable LVAD studies, suggest a minimum left ventricular internal dimension in diastole (LVIDd) of 58 mm, with some clinical practices using a more stringent ≤52 mm cutoff. We retrospectively analyzed 154 consecutive patients supported with Impella 5.5 between January 2020 and December 2024. Overall, 38 patients had an LVIDd ≤58 mm, and 116 had an LVIDd >58 mm; a key subgroup of 21 patients presented with a very small LVIDd of ≤52 mm]. Baseline demographics, comorbidities, body mass index, and renal function were similar [across groups], although those with larger LVIDd had lower ejection fractions (16% vs. 24%, p = 0.001). Median support duration was 24 days in all groups, and pre- and post-implant hemodynamic and laboratory improvements were comparable. Rates of transplantation (79% vs. 90%, p = 0.088) and LVAD implantation (2% vs. 6%, p = 0.159) did not differ significantly in the ≤58 mm cohort. Notably, within the ≤52 mm subgroup, 90-day survival remained high at 90.5% ( p = 0.336), with significant improvements in right atrial pressure (17 to 10 mmHg, p = 0.041), mean pulmonary artery pressure (36 to 26 mmHg, p = 0.008), and eGFR (45 to 57 mL/min/1.73m 2 , p = 0.003). Remarkably, native cardiac recovery was observed exclusively in the smaller LV cohorts, occurring in 11% of the ≤58 mm group ( p = 0.003 vs. 0%, p = 0.003) and reaching 19% in the ≤52 mm group (vs. 0% in larger cavities, p < 0.001), while durable LVAD escalation was entirely avoided in the ≤52 mm cohort (0% vs. 6%). Ninety-day event-free survival was excellent across all cohorts 92% vs. 96% in the primary analysis, with no major device-related complications, suction events, clinically significant hemolysis, bleeding, stroke, or escalation to Bi-VAD support. These findings strongly support the safety and feasibility of Impella 5.5 in extremely constrained, small LV cavities.

Post-transplant lymphoproliferative disorder (PTLD) involving the central nervous system (CNS) is a rare but serious life-threatening complication seen in recipients of solid organ transplant. Primary CNS encompasses 5–15% of all types of PTLD diagnoses, and heart transplant recipients represent 3–5% of those reported cases. Diagnosis is often delayed due to the highly variable presentation, with some cases remaining undiagnosed for years. Multidisciplinary collaboration is crucial for early diagnosis and management. A 53-year-old woman patient presented with altered mental status. MRI revealed nodular ventriculitis and bilateral periventricular hyperdense infiltrates. CSF studies demonstrated lymphocytic pleocytosis, elevated protein, and EBV-PCR-positive results. A stereotactic brain needle biopsy confirmed the presence of EBV-positive diffuse large B-cell lymphoma, consistent with primary CNS PTLD, 14 months after her heart transplant. Despite appropriate management, the patient experienced progressive neurological decline and ultimately suffered a fatal intracerebral hemorrhage. We demonstrate the importance of the early diagnosis and variable presentation of post-heart-transplant PTLD. The importance of surveillance regardless of EBV status and close monitoring of disease progression due to potential life-threatening complications, such as fatal hemorrhages. Therefore, primary CNS-PTLD remains a challenging disease and is being increasingly recognized with improved transplant recipient survival and prolonged exposure to chronic immunosuppression.