Percutaneous coronary intervention with Impella support with and without intra-aortic balloon in cardiogenic shock patients

Combined use of intra-aortic balloon pump and impella in cardiogenic shock: A systematic review

BACKGROUND

Use of Intra-Aortic Balloon Pump (IABP) in combination with Impella has been described as an alternative strategy for mechanical circulatory support (MCS) in patients with cardiogenic shock (CS). We provide a systematic review aimed to explore the effectiveness of this paired MCS approach.

METHODS

We conducted a comprehensive systematic search in MEDLINE, Scopus, and Cochrane databases to identify all studies that investigated dual MCS with IABP and Impella.

RESULTS

Our search strategy identified 12 articles, including 1 randomized controlled trial, 1 retrospective study, 1 case series, 7 case report and 2 animal studies. Rationale for this combined MCS strategy stems from an observed reduction in myocardial oxygen demand/supply ratio compared to the use of each device alone, without determining significant variations in left ventricular work. Nonetheless, this combined approach also leads to a 30-40 % decline in Impella flow, increasing the risk of bleeding, Impella displacement, as well as triggering positioning and pressure alarms. Additionally, hemolytic risk data yielded inconclusive results. Importantly, there were no notable disparities in mortality rates when comparing the combined strategy to the use of each device individually.

CONCLUSION

At the current state-of-the-art, there are no conclusive data demonstrating net clinical benefits of combining Impella with IABP. Considering the substantial risks of morbidity associated, we recommend against its use in clinical practice.

The impact of sex, body mass index and chronic kidney disease on outcomes following percutaneous coronary intervention

OBJECTIVE

This study sought to evaluate 1) the relationship between body mass index (BMI), chronic kidney disease (CKD) and bleeding complications in patients undergoing percutaneous coronary intervention (PCI); and 2) whether CKD modified the effect of BMI on major bleeding and major adverse cardiac and cerebrovascular events (MACCE).

BACKGROUND

The interaction of CKD, sex and BMI in patients undergoing PCI is unclear.

METHODS

Between 2010 and 2018, a total of 31,116 patients underwent PCI at six New York metropolitan area hospitals. Bleeding complications were classified by the Bleeding Academic Research Consortium (BARC). Major bleeding was defined as BARC≥3. MACCE was the composite of in-hospital death; myocardial infarction; cerebrovascular events and major bleeding complications. Interaction on multiplicative scales was assessed adjusting for other factors. A three-way multiplicative interaction between BMI, CKD and sex were considered and evaluated for both endpoints of primary interest (BARC≥3 and MACCE).

RESULTS

Patients with BARC≥3 bleeding were older (p < 0.0001) and more likely female (p < 0.0001). A 3-way interaction existed between sex, BMI, and CKD on BARC≥3 (p = 0.02). Specifically, the effect of CKD status on odds of BARC≥3 depended on BMI group among males, whereas BMI did modify the relationship between CKD and BARC≥3 among females; after stratification by sex, a significant interaction between BMI and CKD was present in females (p = 0.03) but not in males (p = 0.43). Among females without CKD, normal BMI patients had the greatest odds of BARC≥3 compared to obese or overweight females. Contrasted to females without CKD, among females with CKD there was no significant increased odds of BARC≥3 in normal BMI patients compared to obese or overweight females. However, overweight females with CKD had a significantly increased odds of BARC≥3 compared to obese females with CKD. Furthermore, obese females with CKD had significantly greater BARC≥3 odds compared to obese females without CKD. Similarly, overweight females with CKD had an increased odds of BARC≥3 compared to overweight females without CKD. No significant interactions were found for the odds of MACCE.

CONCLUSION

In patients undergoing PCI, there was evidence of a significant and complex 3-way interaction between BMI, CKD and sex for major bleeding events. The predicted probability of major bleeding was greater for females than for male patients, and for both sexes, greater among those with CKD, but BMI group influences these probabilities. Obese females with kidney disease had the lowest incidence of bleeding complications when compared with overweight or normal weight female patients undergoing PCI. This interaction was not seen in the male group or for MACCE. Furthermore, age, cardiogenic shock, STEMI and use of IABP/Impella were each independently associated with odds of major bleeding (among both males and females) and MACCE.

Modelling and Simulation of the Combined Use of IABP and Impella as a Rescue Procedure in Cardiogenic Shock: An Alternative for Non-Transplant Centres?

The treatment of critically ill patients remains an evolving and controversial issue. Mechanical circulatory support through a percutaneous approach for the management of cardiogenic shock has taken place in recent years. The combined use of IABP and the Impella 2.5 device may have a role to play for this group of patients. A simulation approach may help with a quantitative assessment of the achievable degree of assistance. In this paper, we analyse the interaction between the Impella 2.5 pump applied as the LVAD and IABP using the numerical simulator of the cardiovascular system developed in our laboratory. Starting with pathological conditions reproduced using research data, the simulations were performed by setting different rotational speeds for the LVAD and driving the IABP in full mode (1:1) or partial mode (1:2, 1:3 and 1:4). The effects induced by drug administration during the assistance were also simulated. The haemodynamic parameters under investigation were aa follows: mean aortic pressure, systolic and diastolic aortic pressure, mean pulmonary arterial pressure, mean left and right atrial pressure, cardiac output, cardiac index, left and right ventricular end-systolic volume, left ventricular end-diastolic volume and mean coronary blood flow. The energetic variables considered in this study were as follows: left and right ventricular external work and left and right atrial pressure-volume area. The outcome of our simulations shows that the combined use of IABP and Impella 2.5 achieves adequate support in the acute phase of cardiogenic shock compared to each standalone device. This would allow further stabilisation and transfer to a transplant centre should the escalation of treatment be required.