Unexpected rupture of the left ventricular wall following surgical repair of post-infarction ventricular septal rupture in a patient supported by Impella CP: a case report.

Background: Percutaneous ventricular assist devices (pVADs) are important systems in the management of cardiogenic shock, providing effective left ventricular (LV) unloading and enabling preoperative stabilization in critically ill patients. Specifically, their use has expanded to postinfarction ventricular septal rupture (VSR), allowing for delayed surgical intervention once myocardial fibrosis progresses. Nonetheless, mechanical complications associated with prolonged pVAD support, including LV perforation, are rare but potentially fatal. Case summary: A 70-year-old woman developed VSR following an anterior myocardial infarction involving the left anterior descending artery. Preoperatively, the patient was supported with an Impella CP for 7 days. Although the device functioned normally, frequent premature ventricular contractions were noted during support. The patient underwent surgical VSR repair via the right ventricular approach using the extended sandwich patch technique. The Impella CP was removed before aortic cross-clamping. After patch closure and successful weaning from the cardiopulmonary bypass, sudden bleeding was observed in the posterior LV free wall. Re-arrest occurred, and surgical inspection revealed a 1.5-cm subepicardial rupture in the posterior wall, suspected to have resulted from mechanical contact with the Impella catheter tip. The rupture site was repaired using felt-reinforced sutures and surgical sealant. The patient later required temporary mechanical support due to low-output syndrome, but recovered gradually with preserved LV function and no VSR recurrence. Discussion: Even with a pigtail-tipped pVAD, inadequate positioning and prolonged support can lead to LV wall injuries. Careful monitoring, positional assessment, and surgical awareness are essential to avoid such complications.