The RECOVER I: A multicenter prospective study of Impella 5.0/LD for postcardiotomy circulatory support

Temporary Mechanical Circulatory Support after Cardiac Surgery

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.

Outcomes of Impella 5.0 and 5.5 for cardiogenic shock: A single-center 137 patient experience

BACKGROUND

This study evaluated the outcomes of patients with cardiogenic shock (CS) supported with Impella 5.0 or 5.5 and identified risk factors for in-hospital mortality.

METHODS

Adults with CS who were supported with Impella 5.0 or 5.5 at a single institution were included. Patients were stratified into three groups according to their CS etiology: (1) acute myocardial infarction (AMI), (2) acute decompensated heart failure (ADHF), and (3) postcardiotomy (PC). The primary outcome was survival, and secondary outcomes included adverse events during Impella support and length of stay. Multivariable logistic regression was performed to identify risk factors for in-hospital mortality.

RESULTS

One hundred and thirty-seven patients with CS secondary to AMI (n = 47), ADHF (n = 86), and PC (n = 4) were included. The ADHF group had the highest survival rates at all time points. Acute kidney injury (AKI) was the most common complication during Impella support in all 3 groups. Increased rates of AKI and de novo renal replacement therapy were observed in the PC group, and the AMI group experienced a higher incidence of bleeding requiring transfusion. Multivariable analysis demonstrated diabetes mellitus, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine were independent predictors of in-hospital mortality, but the etiology of CS did not impact mortality.

CONCLUSIONS

This study demonstrates that Impella 5.0 and 5.5 provide effective mechanical support for patients with CS with favorable outcomes, with nearly two-thirds of patients alive at 180 days. Diabetes, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine are strong risk factors for in-hospital mortality.

Patient Characteristics and Early Clinical Outcomes With Impella 5.5: A Systematic Review and Meta-Analysis

Data regarding outcomes with Impella 5.5 are limited. The aim of this systematic review and meta-analysis was to summarize patient and treatment characteristics and early clinical outcomes among patients supported by Impella 5.5. A systematic literature search was conducted in PubMed, Scopus, and Cochrane databases from September 2019 to March 2023. Studies reporting outcomes in greater than or equal to 5 patients were included for review. Patient characteristics, treatment characteristics, and early clinical outcomes were extracted. Outcomes included adverse events, survival to hospital discharge, and 30 day survival. Random-effect models were used to estimate pooled effects for survival outcomes. Assessment for bias was performed using funnel plots and Egger's tests. Fifteen studies were included for qualitative review, representing 707 patients. Mean duration of support was 9.9 ± 8.2 days. On meta-analysis of 13 studies reporting survival outcomes, survival to hospital discharge was 68% (95% confidence interval [CI], 58-78%), and 30 day survival was 65% (95% CI, 56-74%) among patients with Impella devices predominantly supported by Impella 5.5 (>60%). There was significant study heterogeneity for these outcomes. Among 294 patients with Impella 5.5 only, survival to discharge was 78% (95% CI, 72-82%) with no significant study heterogeneity. This data present early benchmarks for outcomes with Impella 5.5 as clinical experience with these devices accrues.

Lower extremity artery thromboembolism during removal of Impella after repair for ventricular septal rupture: A case report

Although the anticoagulant complications of Impella are well known, the timing of heparin administration when using Impella immediately after open heart surgery has not been established. We report a case of a 59-year-old man with Impella-assisted repair of a ventricular septal perforation after acute myocardial infarction who developed thromboembolism of the lower extremity arteries after removal of Impella.

Impella - Current issues and future expectations for the percutaneous, microaxial flow left ventricular assist device

The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device.

Temporary mechanical circulatory support with Impella in cardiac surgery: A systematic review

INTRODUCTION

Perioperative cardiogenic shock (CS) in cardiac surgery is still burdened by a high mortality risk. The introduction of Impella pumps in the therapeutic armory of temporary mechanical circulatory support (tMCS) has potential implications to improve the management of complex cases, although it has never been systematically addressed. We performed a systematic review of the reported use of tMCS with Impella in cardiac surgery.

METHODS

We searched PubMed for all original studies on the Impella use in adult patients in cardiac surgery.

RESULTS

Nineteen studies (out of 151 identified by search string) were included. All studies were observational and all but one (95%) were retrospective. Seven studies focused on the implantation of Impella in the pre-operative setting (coronary or valvular surgery), either as a prophylactic device in high-risk cases (3 studies) or in patients with CS as stabilization tool prior to cardiac surgery procedure (4 studies). Three studies reported the use of Impella as periprocedural support for percutaneous valvular procedure, three as bridge to heart replacement, and six for postcardiotomy CS. Impella support had a low complication rate and was successful in supporting hemodynamics pre-, intra- and postoperatively. Most consistently reported data were left-ventricular ejection fraction at implant, short-term survival and weaning rate.

CONCLUSIONS

tMCS with Impella in cardiac surgery patients is feasible and successful. It can be applied in selected cardiac surgery patients and presents advantages over other types of support. Systematic prospective studies are needed to standardize indications for implant and management of surgical issues, and to identify which patients may benefit.

Impact of Impella Support on Clinical Outcomes in Patients with Postcardiotomy Cardiogenic Shock

PURPOSE

This study aimed to elucidate the strategy of an effective Impella support for better clinical outcomes in patients with a postcardiotomy cardiogenic shock (PCCS).

METHODS

This single-center retrospective observational study enrolled 31 patients with PCCS undergoing an elective open-heart surgery followed by Impella support between November 2018 and February 2022 for further analysis.

RESULTS

The preoperative Euroscore II and left ventricular (LV) ejection fraction were 9.1 ± 10.4 and 35.7% ± 12.6%, respectively. The in-hospital mortality rate was 51.6% (n = 16). In survivors (n = 15), the mean Impella support time was 6.9 ± 3.5 days. Patients were discharged on the postoperative day 24.9 ± 16.4. Regarding LV remodeling, LV end-diastolic diameter was significantly decreased after Impella support (59.2 ± 6.0 mm vs. 54.4 ± 4.7 mm, p = 0.01, preoperative vs. postoperative). In-hospital mortality rates were comparable with small (CP, n = 6) or large (5.0, n = 25) Impella systems (33.3% [n = 2] vs. 56.0% [n = 14], p = 0.39). However, a lower in-hospital mortality rate was observed in the group with early initiation (i.e., intraoperative) of Impella support (n = 14) than that with delayed Impella initiation (i.e., in the postoperative course) (n = 11) (28.6% [n = 4] vs. 90.9% [n = 10], p = 0.004).

CONCLUSIONS

Impella support contributes to LV remodeling in PCCS patients. In-hospital mortality was comparable in different Impella sizes and lower in early Impella initiation.

Reconsidering FDA Guidelines: A Single-Center Experience of Prolonged Impella 5.5 Support

OBJECTIVE

Impella 5.5 (Abiomed, Danvers, MA, USA) is approved by the US Food and Drug Administration (FDA) for mechanical circulatory support for ≤14 days. It is unknown whether prolonged support is associated with worse outcomes. We sought to review our single-center experience with Impella 5.5 and compare outcomes based on support duration.

METHODS

We retrospectively reviewed adult patients (≥18 years old) supported with Impella 5.5 at our institution (May 2020 to April 2023). Patients on prolonged support (>14 days) were compared with those supported for ≤14 days.

RESULTS

There were 31 patients supported with Impella 5.5 including 14 (45.2%) supported >14 days. Median support duration for those on prolonged support was 43.5 (interquartile range [IQR] 25 to 63.5) days versus 8 (IQR 6, 13) days for those who were not (P < 0.001). Overall, the device-related complication rate was 9.7% and did not differ between groups (P = 0.08). Overall, 30-day postimplant survival was 71% and did not differ by support duration (P = 0.2). In-hospital mortality was 32% and did not differ between cohorts (P > 0.99). Among those surviving to explant (n = 22), long-term strategy included bridge to durable ventricular assist device (18%, n = 4), cardiac transplant (55%, n = 12), and cardiac recovery (27%, n = 6).

CONCLUSIONS

High-risk patients with cardiogenic shock may be supported with Impella 5.5 beyond the FDA-approved duration without increased risk of complications or mortality.

Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management

Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.

Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery

Objectives

The aim of this study was to explore the associations between percutaneous ventricular assist device (pVAD) insertion timing relative to cardiac surgery and patient outcomes.

Methods

The Nationwide Inpatient Sample was queried for patients undergoing cardiac surgery and pVAD insertion in the same admission from 2016 to 2019. Patients were stratified by timing of pVAD insertion. Preoperative characteristics, postoperative complications, and mortality were compared among groups.

Results

Overall, 3695 patients underwent cardiac surgery and pVAD insertion during the same hospitalization (pre: 1130, intra: 1690, and post: 875). The distribution of cardiac surgery procedures was similar across groups. Median Elixhauser Comorbidity Index was 13 for pre-, 15 for intra-, and 17 for postoperative pVAD patients (P = .021). Patients who received a postoperative pVAD were associated with increased mortality (pre: 18%, intra: 39%, and post: 54%; P < .01). Increased complication rates were also associated with postoperative pVAD insertion (pre: 61%, intra: 55%, and post: 75%; P < .01). Preoperative pVAD insertion was associated with increase rates of sepsis (pre: 18%, intra: 9.8%, and post: 17%; P = .01) and pneumonia (pre: 38%, intra: 23%, and post: 31%; P < .01). Postoperative pVAD insertion was associated with increased rates of gastrointestinal bleeding (pre: 2.2%, intra: 3.0%, and post: 7.4%; P = .01), renal failure (pre: 10%, intra: 9.2%, and post: 17%; P = .01), and prolonged ventilation (pre: 44%, intra: 41%, and post: 54%; P = .02).

Conclusions

Postoperative pVAD insertion following cardiac surgery was associated with increased complications and mortality compared with preoperative or intraoperative insertion. Further studies should explore optimal utilization and timing of pVAD insertion in patients undergoing cardiac surgery.

Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery

Objectives

Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle.

Methods

Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed.

Results

A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation.

Conclusions

The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.

Impella devices: a comprehensive review of their development, use, and impact on cardiogenic shock and high-risk percutaneous coronary intervention

INTRODUCTION

Impella devices have emerged as a critical tool for temporary mechanical circulatory support (TMCS) in the management of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (PCI). The purpose of this review is to examine the history of the different Impella devices, their hemodynamic profiles, and how the data supports their use.

AREAS COVERED

This review covers the development and specifications of the Impella 2.5, Impella CP, Impella 5.0/Left Direct (LD), Impella RP, and Impella 5.5 devices. This review also covers the clinical trials that illuminate the Impella devices' use in their appropriate clinical contexts. These studies examine the effectiveness of Impella devices and have begun to yield promising results, demonstrating improved survival rates when compared to the historically high mortality rates associated with CS. It is important to weigh the benefits of Impella devices in light of their contraindications. A literature search was conducted by searching the PubMed database for reviews, meta-analyses, and clinical trials pertinent to Impella devices.

EXPERT OPINION

Impella devices are a crucial tool for management of patients undergoing high-risk PCI and those with CS. There is evidence that early Impella implantation is beneficial in the treatment of patients presenting with CS. Further randomized controlled trials are needed to better elucidate the benefits of Impella devices in various clinical settings.

Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS.

RECENT FINDINGS

MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy.

Prophylactic LVAD for high-risk patients undergoing cardiac surgery

BACKGROUND

Postcardiotomy cardiogenic shock (PCS) is associated with poor prognosis. Medical therapy with afterload reduction, contractility optimization and systemic vasopressors often fails, and mechanical support is required. The aim of this study was to propose a strategy of prophylactic left ventricular assist device (LVAD) for high-risk patients undergoing cardiac surgery.

METHODS

Between 2013 and 2019, 12 consecutive patients at high risk for PCS underwent cardiac surgery (valve surgery and/or coronary artery bypass grafting) with preplanned, prophylactic implantation of LVAD (CentriMag or Rotaflow). We reviewed patient characteristics and outcomes.

RESULTS

Eight patients underwent a valve corrective surgery and seven patients underwent coronary artery bypass grafting. Eleven of 12 patients had successful LVAD insertion, support and wean, and survival to hospital discharge. Left ventricular function was stable perioperatively and improved at follow-up. Patients required low doses of inotropic support and no patients required extracorporeal membranous oxygenation. Major complications included, prolonged mechanical ventilation (n = 7), intra-aortic balloon pump (n = 1), temporary dialysis (n = 2), stroke (n = 1), bleeding requiring reoperation (n = 3), infection requiring mediastinal washout (n = 1). At a mean follow-up of, 660 ± 460.6 days all patients had either NYHA Class 1 (n = 6) or 2 (n = 4). There were two late mortalities (after 1 year).

CONCLUSIONS

Prophylactic LVAD is a viable technique in select cardiac surgery patients who are high-risk for postcardiotomy shock. Further prospective study is warranted.

Improving Survival in Cardiogenic Shock-A Propensity Score-Matched Analysis of the Impact of an Institutional Allocation Protocol to Short-Term Mechanical Circulatory Support

Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for CS patients and presents outcome data before and after implementation. Data from 421 patients treated for CS with tMCS between 2018 and 2021 were analyzed. In 2019, we implemented a new SOP for allocating CS patients to tMCS modalities. The association between the time of SOP implementation and the 30-day and 1-year survival as well as hospital discharge was evaluated. Of the 421 patients included, 189 were treated before (pre-SOP group) and 232 after implementation of the new SOP (SOP group). Causes of CS included acute myocardial infarction (n = 80, 19.0%), acute-on-chronic heart failure in patients with dilated or chronic ischemic heart failure (n = 139, 33.0%), valvular cardiomyopathy (n = 14, 3.3%) and myocarditis (n = 5, 1.2%); 102 patients suffered from postcardiotomy CS (24.2%). The SOP group was further divided into an SOP-adherent (SOP-A) and a non-SOP-adherent group (SOP-NA). The hospital discharge rate was higher in the SOP group (41.7% vs. 29.7%), and treating patients according to the SOP was associated with an improved 30-day survival (56.9% vs. 38.9%, OR 2.21, 95% CI 1.01-4.80, p = 0.044). Patient allocation according to the presented SOP significantly improved 30-day survival.

Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis

Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.

Rational and Initiative of the Impella in Cardiac Surgery (ImCarS) Register Platform

OBJECTIVES

 Cardiac support systems are being used increasingly more due to the growing prevalence of heart failure and cardiogenic shock. Reducing cardiac afterload, intracardiac pressure, and flow support are important factors. Extracorporeal membrane oxygenation (ECMO) and intracardiac microaxial pump systems (Impella) as non-permanent MCS (mechanical circulatory support) are being used increasingly.

METHODS

 We reviewed the recent literature and developed an international European registry for non-permanent MCS.

RESULTS

 Life-threatening conditions that are observed preoperatively often include reduced left ventricular function, systemic hypoperfusion, myocardial infarction, acute and chronic heart failure, myocarditis, and valve vitia. Postoperative complications that are commonly observed include severe systemic inflammatory response, ischemia-reperfusion injury, trauma-related disorders, which ultimately may lead to low cardiac output (CO) syndrome and organ dysfunctions, which necessitates a prolonged ICU stay. Choosing the appropriate device for support is critical. The management strategies and complications differ by system. The "heart-team" approach is inevitably needed.However despite previous efforts to elucidate these topics, it remains largely unclear which patients benefit from certain systems, when is the right time to initiate (MCS), which support system is appropriate, what is the optimal level and type of support, which therapeutic additive and supportive strategies should be considered and ultimately, what are the future prospects and therapeutic developments.

CONCLUSION

 The European cardiac surgical register ImCarS has been established as an IIT with the overall aim to evaluate data received from the daily clinical practice in cardiac surgery. Interested colleagues are cordially invited to join the register.

CLINICAL REGISTRATION NUMBER

 DRKS00024560.

POSITIVE ETHICS VOTE

 AZ 246/20 Faculty of Medicine, Justus-Liebig-University-Gießen.

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Mechanical circulatory support in cardiogenic shock: a critical appraisal

INTRODUCTION

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD).

AREAS COVERED

Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

EXPERT OPINION

Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.

Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology

The Impella device (Impella, Abiomed, Danvers, MA) is a percutaneous transvalvular microaxial flow pump that is currently used for (1) cardiogenic shock, (2) left ventricular unloading (combination of venoarterial extracorporeal membrane oxygenation and Impella concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion, and coronary blood flow in observational studies and some randomized trials. However, because of the need for large-bore femoral access (14 F for the commonly used Impella CP device) and anticoagulation, the incidences of bleeding and ischemic complications are as much as 44% and 18%, respectively. Hemolysis is reported in as many as 32% of patients and stroke in as many as 13%. Despite the rapidly growing use of the Impella device, there are still insufficient data on its effect on outcome and complications on the basis of large, adequately powered randomized controlled trials. The only 2 small and also underpowered randomized controlled trials in cardiogenic shock comparing Impella versus intra-aortic balloon pump did not show improved mortality. Several larger randomized controlled trials are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock [Danish-German Cardiogenic Shock Trial; NCT01633502]), left ventricular unloading (DTU-STEMI [Door-To-Unload in ST-Segment-Elevation Myocardial Infarction; NCT03947619], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO], and REVERSE [A Prospective Randomised Trial of Early LV Venting Using Impella CP for Recovery in Patients With Cardiogenic Shock Managed With VA ECMO; NCT03431467]) and high-risk percutaneous coronary intervention (PROTECT IV [Impella-Supported PCI in High-Risk Patients With Complex Coronary Artery Disease and Reduced Left Ventricular Function; NCT04763200]).

Early experience with the Impella pump: Single-center registry

BACKGROUND

With the rapid development of mechanical circulatory support technologies, patients presenting with cardiogenic shock have gained access to various treatment opportunities which were not until recently available. The Impella® pump (Abiomed, Danvers, USA) is a minimally invasive device which provides excellent left ventricular unloading and full circulatory support. The aim of the study was to review our center's experience with Impella® and to analyze the major adverse events associated with the device.

METHODS

From January 2020 to January 2022, a total of 32 patients underwent Impella® implantation at our center for various indications.

RESULTS

The mean age at surgery was 60.3 ± 12.4 years and 9.4% were female. All patients presented with acute cardiogenic shock in INTERMACS Class I (53.1%) and INTERMACS Class II (46.9%). Twenty-six patients (81.25%) out of the whole cohort have been mobilized on Impella® support. Seventeen patients (53.1%) have been weaned from the Impella® support and 10 patients (31.3%) have been bridged to durable LVAD. The median time on Impella® was 7 days (IQR 5.0-11.0). 30-day mortality was 37.5%, with 56.25% survival until hospital discharge. Only one patient developed vascular complications consisting of arm hypoperfusion. There were no cases of stroke on Impella® support.

CONCLUSION

The Impella® axial-flow pump seems an appropriate therapeutic option for patients with acute cardiogenic shock requiring partial or full hemodynamic support. It also provides sufficient left ventricular unloading to allow full mobilization and neurological assessment of the patients. Furthermore, Impella® offers a high rate of myocardial recovery.

Perioperative Management of Patients Receiving Short-term Mechanical Circulatory Support with the Transvalvular Heart Pump

Use of the transvalvular heart pump to provide short-term circulatory support in the perioperative setting is growing. The considerations for the perioperative management of patients receiving transvalvular heart pump support are reviewed for the anesthesiologist.

Impella in Transport: Physiology, Mechanics, Complications, and Transport Considerations

Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency. Critical care transport medicine crews are required to transport patient support by the Impella device with increasing frequency. It is important that critical care transport medicine crews are familiar with the Impella device and are able to troubleshoot complications that may arise in the transport environment. This article reviews many aspects of the Impella device critical to the transport of this complex patient population.

Transcarotid Approach to Placement of an Impella 5.0

Microaxial left ventricular assist devices (mLVADs) have traditionally been placed through a transfemoral or transaxillary arterial approach. Transfemoral access is restrictive, significantly limiting postoperative patient ambulation. Transaxillary placement is preferred but not feasible in a subset of patients due to small arterial diameter or tight angulation of the thoracic outlet. Transcarotid delivery has been utilized for other cardiovascular device deployment with good success; however, this approach has not been described for mLVAD support. We present a case series of transcarotid placement of mLVADs in cases where a transaxillary and transfemoral approach was not feasible. From May 2017 to April 2019, six patients in cardiogenic shock required mLVAD support achieved via a transcarotid approach. Technical success was achieved in all patients. One patient was directly weaned from mLVAD support and two patients died on mLVAD support. Escalation to venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required for three patients, two of whom subsequently died. There were no bleeding or valvular complications related to device placement, and no obvious or known neurologic complications related to mLVAD support. Transcarotid placement of mLVADs expands the utility of these devices as an alternative to traditional support strategies or prohibitive arterial anatomy; however, further study is needed to determine its efficacy.

Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy

INTRODUCTION

Trans-valvular micro-axial flow pumps such as Impella are increasingly utilized in patients with cardiogenic shock [CS]. A number of different Impella devices are now available providing a wide range of cardiac output. Among these, the Impella 5.0 and recently introduced Impella 5.5 pumps can provides 5.55 L/min of flow, enabling complete left ventricular support with more favorable hemodynamic effects on myocardial oxygen consumption and left ventricular unloading. These devices require placement of a surgical conduit graft for endovascular delivery, but are increasingly being used in patients with CS due to acutely decompensated heart failure [ADHF], acute myocardial infarction [AMI] and after cardiac surgery as a bridge to transplant or durable ventricular assist device surgery or myocardial recovery.

AREAS COVERED

This review focuses on the device profile and use of the Impella 5.0 and 5.5 systems in patients with CS. Specifically; we reviewed the published literature for Impella 5.0 device to summarize data regarding safety and efficacy.

EXPERT OPINION

The Impella 5.0 and 5.5 are trans-valvular micro-axial flow pumps for which the current data suggest excellent safety and efficacy profiles as approaches to provide circulatory support, myocardial unloading, and axillary placement enabling patient mobilization and rehabilitation.

ABBREVIATIONS

pMCS, Percutaneous mechanical circulatory support devices; CS, Cardiogenic shock; ADHF, Acute decompensated heart failure; AMI, Acute myocardial infarction; LVAD, Left ventricular assist deviceI; ABP, Intra-aortic balloon pump; VA-ECLS, Veno-arterial extracorporeal life support.

Using base excess, albumin, lactate and renal function to predict 30-day mortality in patients requiring impella monotherapy for left-sided mechanical circulatory support: The BALLAR score

OBJECTIVES

To create a simple scoring system that can estimate 30-day mortality in patients requiring left-sided Impella implantation as standalone mechanical circulatory support (MCS).

METHODS

We retrospectively analysed 79 consecutive patients who required left-sided Impella MCS monotherapy. Regression analysis was used to elucidate significant associations between biochemical markers before Impella implantation and all-cause mortality at 30 days. Using these factors, a simple additive scoring system was created using a previously validated approach.

RESULTS

The BALLAR scoring system was created. Patients are assigned points based upon biochemical markers. These are summed and the final points tally provides an estimate of 30-day mortality. The points are assigned as follows: Lactate (mmol/l): ≤1.9: 0 points, 2-4.9: 1 Point, ≥5: 4 Points Creatinine Clearance (ml/min): ≤29.9: 6 points, 30-59.9: 4 points, 60-89.9: 1 point, ≥90: 0 points Serum Albumin (mmol/l): <25: 6 points, 25-34.9: 3 points, ≥35: 0 points Base Excess (mmol/L): < -2: 2 points, ≥-2: 0 points The total score can be used to estimate the probability of death at 30 days. A score less than 6 predicts a 30-day mortality of under 5%, whereas a score over 11 predicts a greater than 95% chance of death within 30 days.

CONCLUSION

Using this simple heuristic predicted 89% of 30-day deaths in our cohort. All the misclassifications were in the intermediate probability range (scores 5-11). This simple scoring system gives an effective estimate of the probability of death at 30 days in our cohort of patients.

Efficacy and safety of Impella 5.0 in cardiogenic shock: an updated systematic review

Aim: The impact on safety and efficacy outcomes of Impella 5.0 in cardiogenic shock (CS) has not been systematically assessed. Materials & methods: We conducted a systematic review of the literature (PROSPERO protocol: CRD42020164680) to critically appraise available evidence on Impella 5.0 comparative safety, efficacy and effectiveness. Results: Of 244 retrieved citations, 17 original articles met the a priori defined inclusion criteria. All included studies had a retrospective study design and, overall, reported on, respectively, 52 and 67 different safety and efficacy/effectiveness outcomes. Thirty-day survival rates ranged from 40 to 94%, myocardial recovery from 18 to 93%. Conclusion: Impella 5.0 provides a full cardiac support, it is associated with a lower rate of vascular complications, it represents a valuable bridge-to-decision and allows for resolution of intercurrent clinical conditions. As available data suggest Impella 5.0 good performance in CS of various etiologies, more solid evidence will come from much-needed large-scale all-comer registries and prospective multicenter randomized trials.

The Effects of Percutaneous Left Ventricular Assist Device Placement on Native Valve Competency

Impella left ventricular assist devices (LVADs) (Abiomed, Danvers, MA) are implanted in the left ventricle across the aortic valve. Several cases of secondary aortic insufficiency (AI) or mitral regurgitation (MR) after Impella LVAD use have been reported. Secondary valvulopathies can worsen cardiac function. This single center retrospective study sought to characterize the incidence of secondary AI and MR development after Impella LVAD support. One hundred fifty-two patients who underwent Impella LVAD support between April 2014 and August 2019 were included. Patient demographics, implant indications, duration of support, pre- and post-Impella LVAD echocardiograms, and incidence of increased AI/MR were analyzed. Impella 5.0 and Impella CP were subanalyzed. Following exclusion criteria, AI and MR were analyzed in 93 and 78 patients, respectively. An increase in AI and MR was seen in 17.2% and 12.8% of patients with an event per support days of 0.03 and 0.02, respectively. Clinically significant increases in AI and MR were seen in 3.2% (n = 3), 6.4% (n = 5), respectively. The incidences of increased AI (p = 0.33) and MR (p = 0.45) were similar between Impella 5.0 and Impella CP patients. Worsening AI and MR clinically occur at a low incidence with Impella LVAD use. However, careful follow-up is still warranted.

Sustained Use of the Impella 5.0 Heart Pump Enables Bridge to Clinical Decisions in 34 Patients

We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.

Utilization and outcomes of postcardiotomy mechanical circulatory support

BACKGROUND

This study evaluated the utilization and outcomes of postcardiotomy mechanical circulatory support (MCS).

METHODS

This was a retrospective, single institution analysis of adult cardiac surgery cases that required de novo MCS following surgery from 2011 to 2018. Patients that were bridged with MCS to surgery were excluded. The primary outcomes were early operative mortality and longitudinal survival. Secondary outcomes included postoperative complications, and 5-year all-cause readmission.

RESULTS

Five hundred and thirty-three patients required de novo postcardiotomy MCS, with the most commonly performed procedure being isolated coronary artery bypass grafting (29.8%). Median cardiopulmonary bypass and cross-clamp times were 185 (IQR 123-260) min and 122 (IQR 81-179) min, respectively. A total of 442 (82.9%) of patients were supported with intra-aortic balloon pump counterpulsation, 23 (4.3%) with an Impella device, and 115 (21.6%) with extracorporeal membrane oxygenation. Three (0.6%) patients had an unplanned ventricular assist device placed. Operative mortality was 29.8%. Longitudinal survival was 56.1% and 43.0% at 1 and 5 years, respectively. Survival was lowest in those supported with ECMO and highest with those supported with an Impella (p < 0.001). Freedom from readmission was 61.4% at 5 years. Postoperative ECMO was an independent predictor of mortality (HR 5.1, 95% CI 2.0-12.9, p < 0.001), but none of the MCS types predicted long-term hospital readmission after risk adjustment.

CONCLUSIONS

Postcardiotomy MCS is associated with high operative mortality. Even patients that survive to discharge have compromised longitudinal survival, with nearly only half surviving to 1 year. Close follow-up and early referral to advanced heart failure specialists may be prudent in improving these outcomes.

Rupture of Papillary Muscle and Chordae Tendinae Complicating STEMI: A Call for Action

Papillary muscle rupture (PMR) or chordae tendinae rupture (CTR) is a rare but lethal complication after ST elevation myocardial infarction (STEMI). Due to the rarity of this condition, there are limited studies defining its epidemiology and outcomes. This is a retrospective study from Nationwide Inpatient Sample database from 2002 to 2014 of patients with STEMI and PMR/CTR. Outcomes of interest were incidence of in-hospital mortality, cardiogenic shock (CS), utilization of mechanical circulatory support (MCS) devices and mitral valve procedures (MVPs) among patients with and without rupture. We also performed simulation using the cardiovascular model to better understand the hemodynamics of severe mitral regurgitation and effects of different medications and device therapy. We identified 1,888 patients with STEMI complicated with PMR/CTR. Most of the patients were >65 years of age (65.3%), male (63.6%), and white (82.3%). They had significantly higher incidence of CS, cardiac arrest, and utilization of MCS devices. In-hospital mortality was higher in patients with rupture (41% vs. 7.40%, p < 0.001) which remained unchanged over the study period. Hospitalization cost and length of stay was also higher in them. MVP and revascularization led to better survival rates (27.9% vs. 60.6%, adjusted OR: 0.14; 95% CI: 0.10-0.19; p < 0.001). Despite significant advancement in the revascularization strategy, PMR/CTR after STEMI continues to portend poor prognosis with high inpatient mortality. Cardiogenic shock is a common presentation and is associated with significantly inpatient mortality. Future studies are needed determine the best strategies to improve outcomes in patients with STEMI with PMR/CTR and CS.

Impella insertion for residual aortic dissection

Acute aortic dissection with coronary malperfusion is a life-threatening disease, resulting in demanding postoperative management. We report a successful insertion of percutaneous heart pump Impella through the intact true lumen in a patient with residual aortic dissection after the graft replacement. Careful evaluation of the access site and the Impella size selection is required.

Clinical features and outcomes in patients with cardiogenic shock complicating acute myocardial infarction: early vs recent experience with impella

OBJECTIVES

To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently.

BACKGROUND

Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably.

METHODS

We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality.

RESULTS

Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort.

CONCLUSIONS

Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.

Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support

Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Axial flow ventricular assist devices in cardiogenic shock complicating acute myocardial infarction

Cardiogenic shock (CS) remains the leading cause of death in patients hospitalised with acute myocardial infarction with mortality as high as 40%-50% prior to hospital discharge. The failure of inotropic therapy to maintain adequate perfusion and to prevent irreversible end-organ failure has led to attempts to improve outcomes by mechanical circulatory support (MCS) devices. Axial flow ventricular assist devices, namely Impella, are an attractive therapeutic option due to their positive haemodynamic benefits and ease of use. Despite clear beneficial haemodynamic effects, which should significantly impact on the pathophysiology of CS, there are currently no clear data to support their use in the reduction of clinical end points such as cardiac death. This review summarises and critically evaluates the current scientific evidence for the use of axial flow ventricular assist devices and highlights gaps in our understanding. Given such gaps, a consensus multidisciplinary approach, predicated on emphasising timely diagnosis and appropriate use of MCS, is vital to ensure that the right patient is paired with the right device at the right time.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

Insertion of Impella CP following postcardiotomy cardiogenic shock concomitant with veno-arterial extracorporeal membrane oxygenation

Postcardiotomy cardiogenic shock (PCCS) is associated with considerably high rates of mortality. In PCCS, veno-arterial extracorporeal membrane oxygenation has been used despite the high rates of complications and poor outcome. Since the introduction of Impella CP (Abiomed, Danvers, MA, USA), effective left-ventricular unloading and systemic perfusion could be maintained even in patients with severe PCCS. Herein, we describe the successful treatment of PCCS following combined heart surgery in a patient by Impella CP insertion.

Large Sheath Management in Patients with Poor Peripheral Access

Despite the evolution of device technology and increasing operator experience, vascular and bleeding complications remain a major source of perioperative morbidity and mortality, particularly in patients with peripheral arterial disease. These complications may be compounded with the use of large bore access sheaths for mechanical support, which may be required to be left in the vessels for a prolonged period of time. Through this article, the authors demonstrate the importance of assessment for peripheral arterial disease before insertion of large bore sheaths. They also describe various strategies to manage occlusive sheaths for distal reperfusion and percutaneous axillary artery access as an alternate option.

Budget Impact Associated with the Introduction of the Impella 5.0® Mechanical Circulatory Support Device for Cardiogenic Shock in France

AIM

Cardiogenic shock (CS), if not diagnosed and treated rapidly, can lead to irreversible multiorgan damage and death. An economic analysis was conducted to determine the budget impact of the introduction of Impella 5.0®, a mechanical circulatory support (MCS) device that directly unloads the left ventricle, into clinical practice in patients with left ventricular CS in France.

METHODS

A budget impact model was developed to compare the cost of Impella 5.0 with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) from the perspective of the French national healthcare insurer. Costs associated with Impella 5.0, plus complication-related costs for VA-ECMO or Impella 5.0 from 2019 were included and clinical input data relating to complication rates and time spent on device were sourced from published literature. Extensive scenario and one-way deterministic sensitivity analyses were performed to explore the influence of uncertainty around key input parameters.

RESULTS

Over a time horizon of 5 years, the introduction of Impella 5.0 was associated with cumulative savings of EUR 4.3 million. The results were driven by the lower risk of device-related complications associated with Impella 5.0. Savings were apparent from Year 1 onwards, with savings in excess of EUR 375,000 projected in Year 1 alone. On a per-patient level, in Year 1, estimated savings with the introduction of Impella 5.0 totaled EUR 616 per patient. Sensitivity analyses showed that the findings of the analysis were robust.

CONCLUSION

The Impella 5.0 device was associated with cumulative cost savings in excess of EUR 4 million over a 5-year period compared with current practice. Projected savings were driven by a lower rate of device-related complications with Impella 5.0 compared with VA-ECMO.

New Surgical Circulatory Support System Outcomes

Supplemental Digital Content is available in the text.

We report the first U.S. experience of the recently approved micro-axial surgical heart pump for the treatment of ongoing cardiogenic shock following acute myocardial infarction (AMICGS), postcardiotomy cardiogenic shock (PCCS), cardiomyopathy including myocarditis, high-risk percutaneous coronary intervention (HRPCI), and coronary artery bypass surgery (HRCABG). Demographic, procedural, hemodynamic, and outcome data were obtained from the manufacturer’s quality database of all Impella 5.5 implants at three centers. Fifty-five patients underwent an Impella 5.5 implant for cardiomyopathy (45%), AMICGS (29%), PCCS (13%), preop CABG (5%), OPCAB (4%), and other (4%). Thirty-five patients (63.6%) were successfully weaned off device with recovery of native heart function. Eleven patients (20.0%) were bridged to another therapy, two patients (3.6%) expired while on support, and in seven patients (12.7%) care was withdrawn. Overall survival was 83.6%. There were no device-related strokes, hemolysis, or limb ischemia observed. Four patients experienced purge sidearm damage, resulting in a pump stop in two patients. The new micro-axial surgical heart pump demonstrated successful clinical and device performance in providing both full hemodynamic support and ventricular unloading for patients with AMICGS, decompensated cardiomyopathy, and high-risk cardiac procedures. In this early U.S. experience, 83.6% of patients survived to explant with 76.1% of these patients recovering native heart function.

Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series

BACKGROUND

Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population.

METHODS

Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration.

RESULTS

All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 h postoperatively with cardiac indices of 2.9-3.6 L/min/m² , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h).

CONCLUSION

Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.

Impella 5.5 Direct Aortic Implant and Explant Techniques

The Impella 5.5 with SmartAssist system (Abiomed, Danvers, MA) is approved for the treatment of cardiogenic shock after acute myocardial infarction, cardiac surgery, or in the setting of cardiomyopathy. Designed for full circulatory support and left ventricular unloading the system comprises a catheter-based microaxial pump placed across the aortic valve, pulling blood from the left ventricle and into the ascending aorta. Implantation can be approached through the axillary artery or directly into the aortic root. We present several technical options for implanting, tunneling, and explanting the system using the direct aortic approach and allowing for bedside removal.

Multimodal mechanical circulatory assist for perioperative biventricular failure

A 61-year-old woman with acute myocardial infarction (MI), cardiogenic shock, and Impella CP support underwent emergency coronary artery bypass grafting. Postoperatively venous-arterial extracorporeal membrane oxygenation (va-ECMO) became necessary, followed by Impella 5.0 insertion on 7th postoperative day (POD), the addition of right ventricular support by TandemHeart due to inadequate flow of Impella system, which then allowed for va-ECMO weaning. Impella und TandemHeart were removed on 14th POD, 31st POD, respectively. Biventricular decompensation following MI was successfully treated by a sequence of different mechanical circulatory support systems allowing an adaptive weaning strategy.