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Chaturvedi A, Rotman Y, Hoang T, Jew G, Mandalapu A, Narins C. CT and chest radiography in evaluation of mechanical circulatory support devices for acute heart failure. Insights Imaging 2023; 14:122. [PMID: 37454301 DOI: 10.1186/s13244-023-01469-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023] Open
Abstract
Acute heart failure and cardiogenic shock are a major cause of morbidity and mortality in patients who have had recent cardiac surgery, myocardial infarct or pulmonary hypertension. The use of percutaneous mechanical circulatory support (MCS) devices before organ failure occurs can improve outcomes in these patients. Imaging plays a key role in identifying appropriate positioning of MCS devices for supporting ventricle function. These devices can be used for left ventricle, right ventricle or biventricular support. Fluoroscopy, angiography and echocardiography are used for implanting these devices. Radiographs and CT can identify both intra- and extra-cardiac complications. The cardiothoracic imager will see increasing use of these devices and familiarity with their normal appearance and complications is important. CRITICAL RELEVANCE STATEMENT: Chest radiographs and CT are useful for assessing the position of the mechanical cardiac support device used for treatment of acute heart failure. CT can identify cardiac and extra-cardiac complications associated with these devices. KEY POINTS: IABP upper/distal marker should be 2-3 cm distal to the ostia of the left subclavian artery. Inlet of Impella CP should be 3.5 cm below the aortic valve. The Impella 5.5 does not have a pigtail portion. The inlet should be about 5 cm below the aortic annulus. Impella RP inlet port should be in the right atrium or inferior vena cava, the pigtail portion should be positioned in the main pulmonary artery. Protek Duo inflow is in the right atrium or right ventricle. The outflow is in the main pulmonary artery.
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Affiliation(s)
- Abhishek Chaturvedi
- Department of Imaging Science, Cardiothoracic Imaging, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14562, USA.
| | - Yonatan Rotman
- Department of Imaging Science, Cardiothoracic Imaging, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14562, USA
| | - Timothy Hoang
- Department of Imaging Science, Cardiothoracic Imaging, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14562, USA
| | - Greg Jew
- Department of Imaging Science, Cardiothoracic Imaging, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14562, USA
| | - Aniruddh Mandalapu
- Department of Imaging Science, Cardiothoracic Imaging, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14562, USA
| | - Craig Narins
- Department of Medicine, Interventional Cardiology, University of Rochester Medical Center, Rochester, NY, USA
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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Abdullah KQA, Roedler JV, vom Dahl J, Szendey I, Haake H, Eckardt L, Topf A, Ohnewein B, Jirak P, Motloch LJ, Wernly B, Larbig R. Impella use in real-world cardiogenic shock patients: Sobering outcomes. PLoS One 2021; 16:e0247667. [PMID: 33635889 PMCID: PMC7909706 DOI: 10.1371/journal.pone.0247667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/10/2021] [Indexed: 11/21/2022] Open
Abstract
Background Critically ill patients with cardiogenic shock could benefit from ventricular assist device support using the Impella microaxial blood pump. However, recent studies suggested Impella not to improve outcomes. We, therefore, evaluated outcomes and predictors in a real-world scenario. Methods In this retrospective single-center trial, 125 patients suffering from cardiac arrest/cardiogenic shock between 2008 and 2018 were analyzed. 93 Patients had a prior successful cardiopulmonary resuscitation. The primary endpoint was hospital mortality. Associations of covariates with the primary endpoint were assessed by univariable and multivariable logistic regression. Adjusted odds ratios (aOR) and optimal cut-offs (using Youden index) were obtained. Results Hospital mortality was high (81%). Baseline lactate was 4.7mmol/L [IQR = 7.1mmol/L]. In multivariable logistic regression, only age (aOR 1.13 95%CI 1.06–1.20; p<0.001) and lactate (aOR 1.23 95%CI 1.004–1.516; p = 0.046) were associated with hospital mortality, and the respective optimal cut-offs were >3.3mmol/L and age >66 years. Patients were retrospectively stratified into three risk groups: Patients aged ≤66 years and lactate ≤3.3mmol (low-risk; n = 22); patients aged >66 years or lactate >3.3mmol/L (medium-risk; n = 52); and patients both aged >66 years and lactate >3.3mmol/L (high-risk, n = 51). Risk of death increased from 41% in the low-risk group, to 79% in the medium risk group and 100% in the high-risk group. The predictive abilities of this model were high (AUC 0.84; 95% 0.77–0.92). Conclusion Mortality was high in this real-world collective of severely ill cardiogenic shock patients. Better patient selection is warranted to avoid unethical use of Impella. Age and lactate might help to improve patient selection.
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Affiliation(s)
- Khaled Q. A. Abdullah
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
- Department of Cardiology, RWTH Aachen University, Aachen, Germany
| | - Jana V. Roedler
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Juergen vom Dahl
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Istvan Szendey
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Hendrik Haake
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Lars Eckardt
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Albert Topf
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Bernhard Ohnewein
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Peter Jirak
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Lukas J. Motloch
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Bernhard Wernly
- Clinic II for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
- Center for Public Health and Healthcare Research, Paracelsus Medical University, Salzburg, Austria
| | - Robert Larbig
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, Mönchengladbach, Germany
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
- * E-mail:
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Monaco F, Di Prima AL, Kim JH, Plamondon MJ, Yavorovskiy A, Likhvantsev V, Lomivorotov V, Hajjar LA, Landoni G, Riha H, Farag A, Gazivoda G, Silva F, Lei C, Bradic N, El-Tahan M, Bukamal N, Sun L, Wang C. Management of Challenging Cardiopulmonary Bypass Separation. J Cardiothorac Vasc Anesth 2020; 34:1622-1635. [DOI: 10.1053/j.jvca.2020.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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Desai SR, Hwang NC. Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Chera HH, Nagar M, Chang NL, Morales-Mangual C, Dous G, Marmur JD, Ihsan M, Madaj P, Rosen Y. Overview of Impella and mechanical devices in cardiogenic shock. Expert Rev Med Devices 2018; 15:293-299. [DOI: 10.1080/17434440.2018.1456334] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Hymie Habib Chera
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Menachem Nagar
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nai-Lun Chang
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - George Dous
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Jonathan D. Marmur
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Muhammad Ihsan
- Division of Cardiology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Miller L. Cardiogenic Shock in Acute Myocardial Infarction: The Era of Mechanical Support. J Am Coll Cardiol 2016; 67:1881-4. [PMID: 27102503 DOI: 10.1016/j.jacc.2015.12.074] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/01/2015] [Indexed: 01/09/2023]
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Ergle K, Parto P, Krim SR. Percutaneous Ventricular Assist Devices: A Novel Approach in the Management of Patients With Acute Cardiogenic Shock. Ochsner J 2016; 16:243-249. [PMID: 27660572 PMCID: PMC5024805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Despite recent advances in the management of heart failure, cardiogenic shock remains a challenging and devastating condition with significant morbidity and mortality. METHODS We review currently available percutaneous mechanical circulatory support (MCS) devices and address each device's characteristics, mechanism of action, specific clinical indications, and contraindications. RESULTS Four types of percutaneous MCS devices are currently available: the intraaortic balloon pump (IABP), Impella devices, the TandemHeart, and extracorporal membrane oxygenation (ECMO). IABPs provide less hemodynamic support compared to the Impella, TandemHeart, and ECMO devices. However, because of its ease of placement and relatively small access catheter size, the IABP remains the most commonly used MCS device for the treatment of cardiogenic shock. When full cardiopulmonary support is needed, ECMO is the best option. CONCLUSION Temporary MCS has emerged as a therapeutic option in the management of patients with acute cardiogenic shock. However, clinician familiarity with the indications, limitations, and benefits of individual MCS devices and enhanced patient comfort with the placement are paramount to improve patient outcomes.
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Affiliation(s)
- Kevin Ergle
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Parham Parto
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Selim R. Krim
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Koprivanac M, Kelava M, Soltesz E, Smedira N, Kapadia S, Brzezinski A, Alansari S, Moazami N. Advances in temporary mechanical support for treatment of cardiogenic shock. Expert Rev Med Devices 2015; 12:689-702. [DOI: 10.1586/17434440.2015.1086265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Update: Acute Heart Failure (VII): Nonpharmacological Management of Acute Heart Failure. ACTA ACUST UNITED AC 2015; 68:794-802. [PMID: 26169327 DOI: 10.1016/j.rec.2015.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 05/11/2015] [Indexed: 11/22/2022]
Abstract
Acute heart failure is a major and growing public health problem worldwide with high morbidity, mortality, and cost. Despite recent advances in pharmacological management, the prognosis of patients with acute decompensated heart failure remains poor. Consequently, nonpharmacological approaches are being developed and increasingly used. Such techniques may include several modalities of ventilation, ultrafiltration, mechanical circulatory support, myocardial revascularization, and surgical treatment, among others. This document reviews the nonpharmacological approach in acute heart failure, indications, and prognostic implications.
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