Published: July 21, 2025
An 18-year-old male with a history of heart transplantation for cardiomyopathy after a durable ventricular assist device presented with progressive cardiac allograft vasculopathy (CAV) and severe diastolic graft failure. The patient presented to the cardiac intensive care unit after a recovered cardiac arrest in extremis with impending multiorgan failure.
He initially underwent placement of an Impella 5.5 percutaneous device surgically through the right subclavian artery into the left ventricle. However, despite having support for the left heart, he continued to struggle with right heart failure.
Patients experiencing graft failure after CAV present multiple challenges to cardiologists. Heart failure is often diastolic, which makes supporting with mechanical devices challenging. In addition to this, with multiple surgeries, their hearts don’t enlarge, which complicates the implantation of traditional durable ventricular assist devices (VADs) such as the HeartMate 3. These patients are also on immune suppression, and large, complicated surgeries markedly increase risk of serious infection. The Impella 5.5 was the best option for him as a minimally invasive percutaneous VAD.
However, after about two weeks of support, the patient developed failure of the right ventricle (RV) after implantation, which can happen in patients with heart failure from multiple causes. There are options for support of the RV, but we still havd the complicating issues outlined above and also needed a minimally invasive option.
Bahaaldin Alsoufi, M.D.
Pediatric cardiothoracic surgeon
Chief, Peediatric Cardiothoracic Surgery
Norton Children’s Heart Institute
ProfessorUofL School of Medicine
Deborah J. Kozik, D.O.
Pediatric Cardiothoracic Surgeon
Norton Children’s Heart InstituteAssociate Professor
UofL School of Medicine
Joshua D. Kurtz, M.D.
Pediatric and adult congential interventional cardiologist
Assistant Professor, Pediatrics
Sarah J. Wilkens, M.D.
Pediatric Heart Failure and Transplantation Cardiologist
Associate director of pediatric advanced heart failure and transplant
Joshua Sparks, M.D.
Associate Professor, Pediatrics
Natalie S. Henderson, M.D.
Pediatric Critical Care Physician
Norton Children’s Critical Care
Michael D. Ruppe, M.D.
Professor, Pediatrics
Bradley Oelkers
ECMO/VAD Manager
Norton Children’s Hospital
Stephanie Gordon
ECMO/VAD Coordinator
In addition, a team of cardiac nurse practitioners, perfusionists, anesthesiologists, nurse clinicians and other dedicated cardiac support staff provided comprehensive care for the patient.
After discussion with our surgical, VAD, and Congenital Heart Failure teams, we worked with Abiomed to acquire the relatively new Impella RP Flex that was placed percutaneously to support the right ventricle. This was done in collaboration with our interventional cardiologist in the catheterization lab with minimal need for anesthesia. The patient then recovered in the Jennifer Lawrence cardiac intensive care unit. With biventricular support, he was able to be awake, watch TV, play video games and rehabilitate in the intensive care unit while awaiting a new heart transplantation.
After about a month of VAD support, the patient was able to undergo a successful heart transplantation. Norton Children’s was the first in the Louisville area to place this device in a patient under age 21 and one of the first pediatric hospitals in the country. The patient recovered and was able to transfer to a local rehabilitation hospital.