This video tutorial demonstrates the feasibility and reproducibility of the Impella 5.5-supported coronary artery bypass procedure as an application of the 'protected cardiac surgery' concept, allowing complete off-pump revascularization in patients with severe left ventricular systolic dysfunction.
Key Findings
Background
Surgical revascularization carries a class I recommendation for ischaemic cardiomyopathy and multivessel coronary artery disease, but carries substantial risk of postoperative low cardiac output syndrome and mortality in patients with severe left ventricular systolic dysfunction.
The paper identifies low cardiac output syndrome and subsequent mortality as key risks of coronary artery bypass grafting (CABG) in this population.
Severe left ventricular systolic dysfunction represents the specific high-risk subset addressed by this technique.
This clinical tension motivates the exploration of pre-emptive mechanical circulatory support strategies.
Background
Off-pump coronary artery bypass grafting may not be feasible in patients with severe left ventricular systolic dysfunction due to intraoperative haemodynamic instability and impaired exposure of the dilated heart.
Avoidance of cardiopulmonary bypass and cardioplegic arrest is the theoretical advantage of off-pump CABG.
However, haemodynamic instability during off-pump manipulation and the physical challenge of exposing a dilated heart are cited as specific barriers in this population.
Pre-emptive mechanical circulatory support is proposed as a solution to these barriers.
Results
The Impella 5.5-supported CABG procedure was successfully performed in a patient with an ejection fraction of 19%, severe left ventricular dilatation, viable myocardium, and three-vessel disease.
The illustrative case featured an ejection fraction of 19%, indicating severely reduced systolic function.
The patient had three-vessel coronary artery disease requiring complete revascularization.
Viable myocardium was confirmed as part of patient selection criteria, justifying revascularization.
Severe left ventricular dilatation was present, compounding the technical difficulty of the procedure.
Results
Complete off-pump revascularization was achieved with the surgically implanted Impella 5.5 microaxial flow pump providing haemodynamic support throughout the procedure.
The Impella 5.5 was surgically implanted as a pre-emptive mechanical circulatory support device.
The device enabled full off-pump revascularization, avoiding cardiopulmonary bypass and cardioplegic arrest.
Planned postoperative support was maintained following the procedure.
The patient underwent eventual awake explantation of the device, indicating successful recovery of haemodynamic stability.
Methods
Patient selection criteria for the Impella 5.5-supported CABG procedure include the presence of viable myocardium, severe left ventricular systolic dysfunction, and multivessel coronary artery disease.
Viability assessment is highlighted as a prerequisite to justify the procedural risk.
The procedure is positioned for patients in whom standard off-pump CABG is deemed not feasible due to haemodynamic fragility.
Preoperative planning is detailed as a structured component of the procedural workflow.
The paper presents patient selection as a critical determinant of procedural success.
Conclusions
The Impella 5.5-supported CABG procedure is presented as a reproducible technique that can serve as the basis for future prospective comparative studies.
The authors state the tutorial 'demonstrates the feasibility and reproducibility of the Impella 5.5-supported coronary artery bypass procedure.'
The authors call for 'future prospective comparative studies to define its eventual role.'
The paper frames this as an application of the broader 'protected cardiac surgery' concept.
The step-by-step video format is intended to enable reproducibility across other centers.
What This Means
This research describes a surgical technique for performing coronary artery bypass grafting (heart bypass surgery) in patients whose hearts are severely weakened, with very low pumping function. In these patients, standard bypass surgery carries high risks of the heart failing to pump adequately after the operation. The team used a device called the Impella 5.5 — a small pump surgically placed into the heart — to support the heart's function throughout the entire operation, allowing surgeons to bypass blocked arteries without needing to stop the heart or use a heart-lung machine. They demonstrated the technique in a patient whose heart was pumping at only 19% of normal capacity and who had blockages in all three major coronary arteries.
The procedure was completed successfully: the patient received full revascularization (all blocked arteries were bypassed), the Impella 5.5 continued supporting the heart after surgery as planned, and eventually the device was removed while the patient was awake — a sign the heart had recovered sufficiently. The paper presents this as a video tutorial, walking through patient selection, planning, and each surgical step, with the goal of making the technique reproducible at other hospitals.
This research suggests that for carefully selected patients with severely weakened hearts and blocked coronary arteries, using a temporary mechanical heart pump during surgery may make it possible to safely perform bypass surgery that might otherwise be too risky. The authors acknowledge this is a single illustrative case and call for larger comparative studies to confirm whether this approach improves patient outcomes compared to existing alternatives.
Heuts S, Natour E, Schreurs R, Körver E, Kuiper G, Dudink R, et al.. (2026). Impella 5.5-supported coronary artery bypass grafting in severe left ventricular dysfunction.. Multimedia manual of cardiothoracic surgery : MMCTS. https://doi.org/10.1510/mmcts.2026.077