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Fried J, Farr M, Kanwar M, Uriel N, Hernandez-Montfort J, Blumer V, Li S, Sinha SS, Garan AR, Li B, Hall S, Hickey GW, Mahr C, Nathan S, Schwartzman A, Kim J, Ton VK, Vishnevsky OA, Vorovich E, Abraham J, Zweck E, Guglin M, Vallabhajosyula S, Kataria R, Walec KD, Zazzali P, Kong Q, Sangal P, Burkhoff D, Kapur NK. Clinical outcomes among cardiogenic shock patients supported with high-capacity Impella axial flow pumps: A report from the Cardiogenic Shock Working Group. J Heart Lung Transplant 2024; 43:1478-1488. [PMID: 38834162 DOI: 10.1016/j.healun.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/09/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND The Impella 5.0 and 5.5 pumps (Abiomed, Danvers, MA) are large-bore transvalvular micro-axial assist devices used in cardiogenic shock (CS) for patients requiring high-capacity flow. Despite their increasing use, real-world data regarding indications, rates of utilization and clinical outcomes with this therapy are limited. The objective of our study was to examine clinical profiles and outcomes of patients in a contemporary, real-world CS registry of patients who received an Impella 5.0/5.5 alone or in combination with other temporary mechanical circulatory support (tMCS) devices. METHODS The CS Working Group (CSWG) Registry includes patients from 34 US hospitals. For this analysis, data from patients who received an Impella 5.0/5.5 between 2020-2023 were analyzed. Use of Impella 5.0/5.5 with or without additional tMCS therapies, duration of support, adverse events and outcomes at hospital discharge were studied. Adverse events including stroke, limb ischemia, bleeding and hemolysis were not standardized by the registry but reported per individual CSWG Primary Investigator discretion. For those who survived, rates of native heart recovery (NHR) or heart replacement therapy (HRT) including heart transplant (HT), or durable ventricular assist device (VAD) were recorded. We also assessed outcomes based on shock etiology (acute myocardial infarction or MI-CS vs. heart failure-related CS or HF-CS). RESULTS Among 6,205 patients, 754 received an Impella 5.0/5.5 (12.1%), including 210 MI-CS (27.8%) and 484 HF-CS (64.1%) patients. Impella 5.0/5.5 was used as the sole tMCS device in 32% of patients, while 68% of patients received a combination of tMCS devices. Impella cannulation sites were available for 524/754 (69.4%) of patients, with 93.5% axillary configuration. Survival to hospital discharge for those supported with an Impella 5.0/5.5 was 67%, with 20.4% NHR and 45.5% HRT. Compared to HF-CS, patients with MI-CS supported on Impella 5.0/5.5 had higher in-hospital mortality (45.2% vs 26.2%, p < 0.001) and were less likely to receive HRT (22.4% vs 56.6%, p < 0.001. For patients receiving a combination of tMCS during hospitalization, this was associated with higher rates of limb ischemia (9% vs. 3%, p < 0.01), bleeding (52% vs 33%, p < 0.01), and mortality (38% vs 25%; p < 0.001) compared to Impella 5.0/5.5 alone. Among Impella 5.0/5.5 recipients, the median duration of pump support was 12.9 days (IQR: 6.8-22.9) and longer in patients bridged to HRT (14 days; IQR: 7.7-28.4). CONCLUSIONS In this multi-center cohort of patients with CS, use of Impella 5.0/5.5 was associated with an overall survival of 67.1% and high rates of HRT. Lower adverse event rates were observed when Impella 5.0/5.5 was the sole support device used. Further study is required to determine whether a strategy of early Impella 5.0/5.5 use for CS improves survival. CONDENSED ABSTRACT High capacity Impella heart pumps are capable of provide up to 5.5 liter/min of flow while upper body surgical placement allows for ambulation. Patients with advanced cardiogenic shock from acute myocardial infarction or heart failure requiring temporary mechanical circulatory support may benefit from upfront use of Impella 5.5 to improve overall survival, including native heart recovery or successful bridge to durable left ventricular assist device surgery or heart transplantation.
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Affiliation(s)
- Justin Fried
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Maryjane Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nir Uriel
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | | | - Vanessa Blumer
- Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | - Song Li
- Medical City Healthcare, Dallas, Texas
| | - Shashank S Sinha
- Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | - A Reshad Garan
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Sandeep Nathan
- The University of Chicago Heart and Vascular Center, Chicago, Illinois
| | | | - Ju Kim
- Houston Methodist Research Institute, Houston, Texas
| | - Van-Khue Ton
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Oleg A Vishnevsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Esther Vorovich
- Division of Cardiology, Northwestern Medicine, Chicago, Illinois
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Portland, Oregon
| | - Elric Zweck
- Department of Cardiology, Pulmonary and Vascular Medicine, University Hospital Dusseldorf, Dusseldorf, Germany
| | - Maya Guglin
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Saraschandra Vallabhajosyula
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Rachna Kataria
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Karol D Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Qiuyue Kong
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Paavani Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
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Hong Y, Dorken-Gallastegi A, Nasim U, Hess NR, Ziegler LA, Abdullah M, Iyanna N, Ramanan R, Hickey GW, Kaczorowski DJ. Extended Duration of Impella 5.5 Support Does Not Adversely Impact Outcomes Following Heart Transplantation: A National Registry Analysis. ASAIO J 2024:00002480-990000000-00545. [PMID: 39150765 DOI: 10.1097/mat.0000000000002296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
Prior studies assessing the effects of Impella 5.5 support duration on posttransplant outcomes have been limited to single-center case reports and series. This study evaluates the impact of Impella 5.5 support duration on outcomes following heart transplantation using the United Network for Organ Sharing database. Adult heart transplant recipients who were directly bridged to primary isolated heart transplantation with Impella 5.5 were included. The cohort was stratified into two groups based on the duration of Impella support: less than or equal to 14 and greater than 14 days. The primary outcome was 90 day posttransplant survival. Propensity score matching was performed. Sub-analysis was conducted to evaluate the impact of greater than 30 days of Impella support on 90 day survival. Three hundred thirty-two recipients were analyzed. Of these, 212 recipients (63.9%) were directly bridged to heart transplantation with an Impella support duration of greater than 14 days. The two groups had comparable 90 day posttransplant survival and complication rates. The comparable posttransplant survival persisted in a propensity score-matched comparison. In the sub-analysis, Impella support duration of greater than or equal to 30 days did not adversely impact 90 day survival. This study demonstrates that extended duration of support with Impella 5.5 as a bridge to transplantation does not adversely impact posttransplant outcomes. Impella 5.5 is a safe and effective bridging modality to heart transplantation.
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Affiliation(s)
- Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Umar Nasim
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Luke A Ziegler
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mohamed Abdullah
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt
| | - Nidhi Iyanna
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Pieri M, Ortalda A, Altizio S, Bertoglio L, Nardelli P, Fominskiy E, Lapenna E, Ajello S, Scandroglio AM. Prolonged Impella 5.0/5.5 support within different pathways of care for cardiogenic shock: the experience of a referral center. Front Cardiovasc Med 2024; 11:1379199. [PMID: 39015682 PMCID: PMC11250607 DOI: 10.3389/fcvm.2024.1379199] [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] [Received: 01/30/2024] [Accepted: 06/03/2024] [Indexed: 07/18/2024] Open
Abstract
Aims Impella 5.0 and 5.5 are promising low-invasive left ventricle (LV) temporary mechanical circulatory supports (tMCS) for cardiogenic shock due to LV mechanical unloading and are paired with powerful hemodynamic support. This study aimed to analyze data and destinies of patients supported with Impella 5.0/5.5 at a national referral center for cardiogenic shock and to assess the parameters associated with myocardial recovery and successful weaning. Methods A single-center observational study was conducted on all patients treated with Impella 5.0 or 5.5 from March 2018 to July 2023. Results A total of 59 patients underwent Impella 5.0/5.5 implantation due to profound cardiogenic shock, with acute myocardial infarction being the most frequent cause of shock (42 patients, 71%). The median duration of Impella support was 13 days (maximum duration of 52 days). Axillary cannulation was feasible in almost all patients, and 36% were mobilized during support. A total of 44 patients (75%) survived to the next therapy/recovery: 21 patients experienced recovery and 15 and 8 were bridged to long-term LVAD and heart transplantation, respectively. The global survival rate was 66%. The predictors of native heart recovery at multivariate analysis were the number of days on tMCS before upgrade to Impella 5.0/5.5 [hazard ratio (HR) 0.68 (0.51-9) p = 0.0068] and improvement of LVEF within the first 7-10 days of support [HR 4.72 (1.34-16.7), p = 0.016]. Conclusions Transcatheter systems such as Impella 5.0/5.5 revolutionized the field of tMCS. Myocardial recovery is the primary clinical target. Its prognostication and promotion are key to ensure the most proficuous course for each patient from cardiogenic shock to long-term event-free survival.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- School of Medicine, Brescia University School of Medicine, Brescia, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Ardito V, Rognoni C, Pieri M, Barbone A, Briguori C, Cigala E, Gerosa G, Iannaccone M, Loforte A, Marini M, Montalto A, Oreglia J, Pacini D, Pennacchi M, Pestrichella V, Porto I, Stefano P, Tarantini G, Valente S, Vandoni P, Tarricone R, Scandroglio AM. Impella versus VA-ECMO for the treatment of patients with cardiogenic shock: the Impella Network Project - observational study protocol for cost-effectiveness and budget impact analyses. BMJ Open 2024; 14:e078358. [PMID: 38926145 PMCID: PMC11216050 DOI: 10.1136/bmjopen-2023-078358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION The treatment of patients with cardiogenic shock (CS) encompasses several health technologies including Impella pumps and venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, while they are widely used in clinical practice, information on resource use and quality of life (QoL) associated with these devices is scarce. The aim of this study is, therefore, to collect and comparatively assess clinical and socioeconomic data of Impella versus VA-ECMO for the treatment of patients with severe CS, to ultimately conduct both a cost-effectiveness (CEA) and budget impact (BIA) analyses. METHODS AND ANALYSIS This is a prospective plus retrospective, multicentre study conducted under the scientific coordination of the Center for Research on Health and Social Care Management of SDA Bocconi School of Management and clinical coordination of Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute in Milan. The Impella Network stemmed for the purposes of this study and comprises 17 Italian clinical centres from Northern to Southern Regions in Italy. The Italian network qualifies as a subgroup of the international Impella Cardiac Surgery Registry. Patients with CS treated with Impella pumps (CP, 5.0 or 5.5) will be prospectively recruited, and information on clinical outcomes, resource use and QoL collected. Economic data will be retrospectively matched with data from comparable patients treated with VA-ECMO. Both CEA and BIA will be conducted adopting the societal perspective in Italy. This study will contribute to generate new socioeconomic evidence to inform future coverage decisions. ETHICS AND DISSEMINATION As of May 2024, most of the clinical centres submitted the documentation to their ethical committee (N=13; 76%), six centres received ethical approval and two centres started to enrol patients. Study results will be published in peer-reviewed publications and disseminated through conference presentations.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | | | - Carlo Briguori
- Mediterranea Cardiocentro, Clinica Mediterranea SpA, Napoli, Italy
| | - Emanuele Cigala
- UOC Cardiologia Interventistica, Ospedale Monaldi, Napoli, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy
| | - Antonio Loforte
- Dipartimento di Scienze Chirurgiche, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Marini
- Dipartimento di Scienze Cardiovascolari, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Andrea Montalto
- Azienda Ospedaliera di Caserta Sant'Anna e San Sebastiano, Caserta, Italy
| | | | | | - Mauro Pennacchi
- Dipartimento Cardio Toraco Vascolare, U.O. Cardiologia Interventistica, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | | | - Italo Porto
- DICATOV-CardioThoracic and Vascular, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
- University of Genova, Policlinico San Martino IRCCS, Università degli Studi di Genova Scuola di Scienze Mediche e Farmaceutiche, Genova, Italy
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | | | | | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milano, Italy
- Department of Social and Political Sciences, Bocconi University, Milano, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Italy
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Gyoten T, Amiya E, Saito A, Ono M. Predictors of long-term success after successful explantation of continuous flow left ventricular assist device support. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae091. [PMID: 38830049 DOI: 10.1093/icvts/ivae091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/02/2024] [Accepted: 05/01/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Predictors and evaluations of continuous flow left ventricular assist device (cf-LVAD) explantation in recovered patients remain under discussion due to lack of evidence on long-term safety and efficacy. This study summarized our experiences regarding cf-LVAD explantation in non-ischaemic dilated cardiomyopathy patients and estimated a predictor for sufficient myocardial recovery allowing left ventricular assist device explant. METHODS We retrospectively identified 135 adult patients with cf-LVAD therapy as bridge to heart transplant due to non-ischaemic dilated cardiomyopathy. Of those, 13 patients underwent device explantation (recovery group) after myocardial recovery. Twelve (92%) of the explanted patients were evaluated using our weaning protocol and underwent surgical explantation. Meanwhile, the remaining 122 continued with cf-LVAD therapy (non-recovery group). RESULTS Multivariate logistic regression analysis revealed time interval between the first heart failure event and cf-LVAD implantation as an independent predictor for successful explantation. The optimal time interval cutoff value to predict cf-LVAD explantation was 7 months, with a sensitivity of 91.0% and specificity of 84.6%. Echocardiography in patients with successful cf-LVAD explantation showed significant improvement of left ventricular function and dimensions at 6 months postoperatively. The 13 explanted patients are currently alive at a median of 30 (interquartile range; 18-58) months after explantation. The survival rate free from rehospitalization due to heart failure following explantation was 100%. Left ventricular function and remodelling after explantation were also preserved. CONCLUSIONS In non-ischaemic dilated cardiomyopathy patients with a short interval between the first heart failure event and cf-LVAD therapy, left ventricular myocardium may recover in an early phase after device implantation.
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Affiliation(s)
- Takayuki Gyoten
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
- Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
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Kieserman JM, Kuznetsov IA, Park J, Schurr JW, Toubat O, Olia S, Bermudez C, Cevasco M, Wald J. Left ventricular unloading via percutaneous assist device during extracorporeal membrane oxygenation in acute myocardial infarction and cardiac arrest. Int J Artif Organs 2024; 47:401-410. [PMID: 38853663 DOI: 10.1177/03913988241254978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
INTRODUCTION A feared complication of an acute myocardial infarction (AMI) is cardiac arrest (CA). Even if return of spontaneous circulation is achieved, cardiogenic shock (CS) is common. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) supports patients with CS and is often used in conjunction with an Impella device (2.5 and CP) to off-load the left ventricle, although limited evidence supports this approach. METHODS The goal of this study was to determine whether a mortality difference was observed in VA-ECMO alone versus VA-ECMO with Impella (ECPELLA) in patients with CS from AMI and CA. A retrospective chart review of 50 patients with AMI-CS and CA and were supported with VA-ECMO (n = 34) or ECPELLA (n = 16) was performed. The primary outcome was all-cause mortality at 6-months from VA-ECMO or Impella implantation. Secondary outcomes included in-hospital mortality and complication rates between both cohorts and intensive care unit data. RESULTS Baseline characteristics were similar, except patients with ST-elevation myocardial infarction were more likely to be in the VA-ECMO group (p = 0.044). The ECPELLA cohort had significantly worse survival after VA-ECMO (SAVE) score (p = 0.032). Six-month all-cause mortality was not significantly different between the cohorts, even when adjusting for SAVE score. Secondary outcomes were notable for an increased rate of minor complications without an increased rate of major complications in the ECPELLA group. CONCLUSIONS Randomized trials are needed to determine if a mortality difference exists between VA-ECMO and ECPELLA platforms in patients with AMI complicated by CA and CS.
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Affiliation(s)
- Jake M Kieserman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ivan A Kuznetsov
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph Park
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - James W Schurr
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Omar Toubat
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salim Olia
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Xenitopoulou MP, Ziampa K, Evangeliou AP, Tzikas S, Vassilikos V. Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock. J Clin Med 2024; 13:2642. [PMID: 38731171 PMCID: PMC11084767 DOI: 10.3390/jcm13092642] [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: 03/16/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.
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Affiliation(s)
| | | | | | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
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Walther CP. Cardiac Devices and Kidney Disease. Semin Nephrol 2024; 44:151513. [PMID: 38760291 DOI: 10.1016/j.semnephrol.2024.151513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
A growing variety of cardiac devices are available to monitor or support cardiovascular function. The entwined nature of cardiovascular disease and kidney disease makes the relationship of these devices with kidney disease a multifaceted question relating to the use of these devices in individuals with kidney disease and to the effects of the devices and device placement on kidney health. Cardiac devices can be categorized broadly into cardiac implantable electronic devices, structural devices, and circulatory assist devices. Cardiac implantable electronic devices include devices for monitoring and managing cardiac electrical activity and devices for monitoring hemodynamics. Structural devices modify cardiac structure and include valve prostheses, valve repair clips, devices for treating atrial septal abnormalities, left atrial appendage closure devices, and interatrial shunt devices. Circulatory assist devices support the failing heart or support cardiac function during high-risk cardiac procedures. Evidence for the use of these devices in individuals with kidney disease, effects of the devices on kidney health and function, specific considerations with devices in kidney disease, and important knowledge gaps are surveyed in this article. With the growing prevalence of combined cardiorenal disease and the increasing variety of cardiac devices, kidney disease considerations are an important aspect of device therapy.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
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Bhatt HV, Fritz AV, Feinman JW, Subramani S, Malhotra AK, Townsley MM, Weiner MM, Sharma A, Teixeira MT, Lee J, Linganna RE, Waldron NH, Shapiro AB, Mckeon J, Hanada S, Ramakrishna H, Martin AK. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024; 38:16-28. [PMID: 38040533 DOI: 10.1053/j.jvca.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 12/03/2023]
Abstract
This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Regina E Linganna
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nathan H Waldron
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Bovill Shapiro
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - John Mckeon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Satoshi Hanada
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
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Sicke M, Modi S, Hong Y, Bashline M, Klass W, Horn E, Hansra BS, Ramanan R, Fowler J, Sumzin N, Rivosecchi RM, Chaudhary R, Ziegler LA, Hess NR, Agrawal N, Kaczorowski DJ, Hickey GW. Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5. Int J Artif Organs 2024; 47:8-16. [PMID: 38053245 PMCID: PMC10824236 DOI: 10.1177/03913988231214180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Despite historical differences in cardiogenic shock (CS) outcomes by etiology, outcomes by CS etiology have yet to be described in patients supported by temporary mechanical circulatory support (MCS) with Impella 5.5. OBJECTIVES This study aims to identify differences in survival and post-support destination for these patients in acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) CS at a high-volume, tertiary, transplant center. METHODS A retrospective review of patients who received Impella 5.5 at our center from November 2020 to June 2022 was conducted. RESULTS Sixty-seven patients underwent Impella 5.5 implantation for CS; 23 (34%) for AMI and 44 (66%) for ADHF. AMI patients presented with higher SCAI stage, pre-implant lactate, and rate of prior MCS devices, and fewer days from admission to implantation. Survival was lower for AMI patients at 30 days, 90 days, and discharge. No difference in time to all-cause mortality was found when excluding patients receiving transplant. There was no significant difference in complication rates between groups. CONCLUSIONS ADHF-CS patients with Impella 5.5 support have a significantly higher rate of survival than patients with AMI-CS. ADHF patients were successfully bridged to heart transplant more often than AMI patients, contributing to increased survival.
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Affiliation(s)
- McKenzie Sicke
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shan Modi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Michael Bashline
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wyatt Klass
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ed Horn
- Department of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barinder S Hansra
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nikita Sumzin
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahul Chaudhary
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luke A Ziegler
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Nishant Agrawal
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Gavin W Hickey
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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11
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Valdes CA, Stinson G, Sharaf OM, Jimenez Contreras F, Bilgili A, Ahmed MM, Vilaro J, Parker AM, Al-Ani MAZ, Demos D, Aranda J, Bleiweis M, Beaver TM, Jeng EI. Reconsidering FDA Guidelines: A Single-Center Experience of Prolonged Impella 5.5 Support. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:46-53. [PMID: 38013250 DOI: 10.1177/15569845231212157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
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.
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12
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Al-Ani MA, Bai C, Bledsoe M, Ahmed MM, Vilaro JR, Parker AM, Aranda JM, Jeng E, Shickel B, Bihorac A, Peek GJ, Bleiweis MS, Jacobs JP, Mardini MT. Utilization of the percutaneous left ventricular support as bridge to heart transplantation across the United States: In-depth UNOS database analysis. J Heart Lung Transplant 2023; 42:1597-1607. [PMID: 37307906 DOI: 10.1016/j.healun.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/12/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Intra-aortic balloon pump (IABP) and Impella device utilization as a bridge to heart transplantation (HTx) have risen exponentially. We aimed to explore the influence of device selection on HTx outcomes, considering regional practice variation. METHODS A retrospective longitudinal study was performed on a United Network for Organ Sharing (UNOS) registry dataset. We included adult patients listed for HTx between October 2018 and April 2022 as status 2, as justified by requiring IABP or Impella support. The primary end-point was successful bridging to HTx as status 2. RESULTS Of 32,806 HTx during the study period, 4178 met inclusion criteria (Impella n = 650, IABP n = 3528). Waitlist mortality increased from a nadir of 16 (in 2019) to a peak of 36 (in 2022) per thousand status 2 listed patients. Impella annual use increased from 8% in 2019 to 19% in 2021. Compared to IABP, Impella patients demonstrated higher medical acuity and lower success rate of transplantation as status 2 (92.1% vs 88.9%, p < 0.001). The IABP:Impella utilization ratio varied widely between regions, ranging from 1.77 to 21.31, with high Impella use in Southern and Western states. However, this difference was not justified by medical acuity, regional transplant volume, or waitlist time and did not correlate with waitlist mortality. CONCLUSIONS The shift in utilizing Impella as opposed to IABP did not improve waitlist outcomes. Our results suggest that clinical practice patterns beyond mere device selection determine successful bridging to HTx. There is a critical need for objective evidence to guide tMCS utilization and a paradigm shift in the UNOS allocation system to achieve equitable HTx practice across the United States.
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Affiliation(s)
- Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida.
| | - Chen Bai
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| | - Maisara Bledsoe
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Eric Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Benjamin Shickel
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Giles J Peek
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mark S Bleiweis
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mamoun T Mardini
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
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13
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Cevasco M, Shin M, Cohen W, Helmers MR, Weingarten N, Rekhtman D, Wald JW, Iyengar A. Impella 5.5 as a bridge to heart transplantation: Waitlist outcomes in the United States. Clin Transplant 2023; 37:e15066. [PMID: 37392194 DOI: 10.1111/ctr.15066] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/24/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES The 2018 United Network for Organ Sharing allocation policy change has led to a significant increase in the use of mechanical circulatory support devices in patients listed for orthotopic heart transplantation. However, there has been a paucity of data regarding the newest generation Impella 5.5, which received FDA approval in 2019. METHODS The United Network for Organ Sharing registry was queried for all adults awaiting orthotopic heart transplantation who received Impella 5.5 support during their listing period. Waitlist, device, and early post-transplant outcomes were assessed. RESULTS A total of 464 patients received Impella 5.5 support during their listing period with a median waitlist time of 19 days. Among them, 402 (87%) patients were ultimately transplanted, with 378 (81%) being directly bridged to transplant with the device. Waitlist death (7%) and clinical deterioration (5%) were the most common reasons for waitlist removal. Device complications and failure were uncommon (<5%). The most common post-transplant complication was acute kidney injury requiring dialysis (16%). Survival at 1-year post-transplant survival was 89.5%. CONCLUSION Since its approval, the Impella 5.5 has been increasingly used as a bridge to transplant. This analysis demonstrates robust waitlist and post-transplant outcomes with minimal device-related and postoperative complications.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce W Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aslam MI, Gruslova AB, Almomani A, Nolen D, Elliott JJ, Jani VP, Kottam A, Porterfield J, Heighten C, Anderson AS, Valvano JW, Feldman MD. Modification of a Transvalvular Microaxial Flow Pump for Instantaneous Determination of Native Cardiac Output and Volume. J Card Fail 2023; 29:1369-1379. [PMID: 37105397 DOI: 10.1016/j.cardfail.2023.04.007] [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: 11/21/2022] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. OBJECTIVES This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. METHODS Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. RESULTS Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. CONCLUSIONS We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. CONDENSED ABSTRACT Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.
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Affiliation(s)
- M Imran Aslam
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Aleksandra B Gruslova
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ahmed Almomani
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Drew Nolen
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - James J Elliott
- Department of Laboratory Animal Resources, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Vivek P Jani
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anil Kottam
- BridgeSource Medical Corporation, Austin, Texas
| | | | | | - Allen S Anderson
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jonathan W Valvano
- Department of Electrical Engineering, University of Texas at Austin, Austin, Texas
| | - Marc D Feldman
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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Sommer W, Arif R, Kremer J, Al Maisary S, Verch M, Tochtermann U, Karck M, Meyer AL, Warnecke G. Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery. JTCVS OPEN 2023; 15:252-260. [PMID: 37808068 PMCID: PMC10556953 DOI: 10.1016/j.xjon.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 10/10/2023]
Abstract
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.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sameer Al Maisary
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus Verch
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anna L. Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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16
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Isath A, Ohira S, Levine A, Lanier GM, Pan S, Aggarwal-Gupta C, Mason I, Gregory V, Spielvogel D, Gass AL, Kai M. Evolution of concomitant use of veno-arterial extracorporeal membrane oxygenation support with Impella in cardiogenic shock: From percutaneous femoral Impella to axillary Impella 5.5. Artif Organs 2023; 47:1404-1412. [PMID: 37335815 DOI: 10.1111/aor.14594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/05/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Little is known about safety and efficacy of the use of Impella 5.5 compared to previous iterations in the setting of Impella with Veno-Arterial Extracorporeal Membrane Oxygenation Support as ECPELLA. METHODS Consecutive patients who were treated by ECPELLA with surgically implanted axillary Impella 5.5 (N = 13) were compared with patients supported by ECPELLA with percutaneous femoral Impella CP or 2.5 (Control, N = 13). RESULTS The total ECPELLA flow was higher in ECPELLA 5.5 group (6.9 vs. 5.4 L/min, p = 0.019). Actual hospital survival was higher than predicted and comparable in both groups (ECPELLA 5.5, 61.5% vs. Control, 53.8%, p = 0.691). Both total device complications (ECPELLA 5.5, 7.7% vs. Control, 46.1%, p = 0.021) and Impella-specific complications (ECPELLA 5.5, 0% vs. Control, 30.8%, p = 0.012) were significantly lower in the ECPELLA 5.5 group. CONCLUSIONS Utilization of Impella 5.5 in the setting of ECPELLA provides greater hemodynamic support with a lower risk of complications compared to Impella CP or 2.5.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Chhaya Aggarwal-Gupta
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Ian Mason
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vasiliki Gregory
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Alan L Gass
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
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17
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Dalia T, Pothuru S, Chan WC, Mehta H, Goyal A, Farhoud H, Boda I, Malhotra A, Vidic A, Rali AS, Hanff TC, Gupta K, Fang JC, Shah Z. Trends and Outcomes of Cardiogenic Shock in Patients With End-Stage Renal Disease: Insights From USRDS Database. Circ Heart Fail 2023; 16:e010462. [PMID: 37503601 PMCID: PMC11270562 DOI: 10.1161/circheartfailure.122.010462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis). METHODS This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients. RESULTS A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients (Ptrend<0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 (Ptrend=0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 (Ptrend=0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 (Ptrend<0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 (Ptrend<0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients (Ptrend<0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P=0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality. CONCLUSIONS The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support.
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Affiliation(s)
- Tarun Dalia
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Suveenkrishna Pothuru
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Harsh Mehta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Amandeep Goyal
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Hassan Farhoud
- Medical Student, Class of 2023, University of Kansas Medical Center (H.F.)
| | - Ilham Boda
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Anureet Malhotra
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Andrija Vidic
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.S.R.)
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
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Xu Z, Chen C, Hao P, He F, Zhang X. Cell-scale hemolysis evaluation of intervenient ventricular assist device based on dissipative particle dynamics. Front Physiol 2023; 14:1181423. [PMID: 37476687 PMCID: PMC10354560 DOI: 10.3389/fphys.2023.1181423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/26/2023] [Indexed: 07/22/2023] Open
Abstract
Most of the existing hemolysis mechanism studies are carried out on the macro flow scale. They assume that the erythrocyte membranes with different loads will suffer the same damage, which obviously has limitations. Thus, exploring the hemolysis mechanism through the macroscopic flow field information is a tough challenge. In order to further understand the non-physiological shear hemolysis phenomenon at the cell scale, this study used the coarse-grained erythrocytes damage model at the mesoscopic scale based on the transport dissipative particle dynamics (tDPD) method. Combined with computational fluid dynamics the hemolysis of scalarized shear stress (τ) in the clearance of "Impella 5.0" was evaluated under the Lagrange perspective and Euler perspective. The results from the Lagrange perspective showed that the change rate of scaled shear stress (τ˙) was the most critical factor in damaging RBCs in the rotor region of "Impella 5.0"and other transvalvular micro-axial blood pumps. Then, we propose a dimensionless number Dk with time integration based on τ˙ to evaluate hemolysis. The Dissipative particle dynamics simulation results are consistent with the Dk evaluation results, so τ˙ may be an important factor in the hemolysis of VADs. Finally, we tested the hemolysis of 30% hematocrit whole blood in the "Impella 5.0" shroud clearance from the Euler perspective. Relevant results indicate that because of the wall effect, the RBCs near the impeller side are more prone to damage, and most of the cytoplasm is also gathered at the rotor side.
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Affiliation(s)
- Zhike Xu
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
| | - Chenghan Chen
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
| | - Pengfei Hao
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
- School of Materials Science and Engineering, AVIC Aerodynamics Research Institute Joint Research Center for Advanced Materials and Anti-Icing, Tsinghua University, Beijing, China
| | - Feng He
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
| | - Xiwen Zhang
- Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing, China
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19
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George TJ, Sheasby J, DiMaio JM, Kabra N, Rawitscher DA, Afzal A. Outcomes of surgical Impella placement in acute cardiogenic shock. Proc AMIA Symp 2023; 36:415-421. [PMID: 37334083 PMCID: PMC10269385 DOI: 10.1080/08998280.2023.2205817] [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: 01/11/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Although a role for percutaneous Impella devices has been established, there is a paucity of data regarding the utility and outcomes of larger surgically implanted Impella devices. Methods We conducted a retrospective review of all surgical Impella implants at our institution. All Impella 5.0 and Impella 5.5 devices were included. The primary outcome was survival. Secondary outcomes included hemodynamic and end-organ perfusion as well as commonly encountered surgical complications. Results From 2012 to 2022, 90 surgical Impella devices were implanted. The median age was 63 [53-70] years, the mean creatinine was 2.07 ± 1.22 mg/dL, and the average lactate level was 3.32 ± 2.90 mmol/L. Prior to implantation, 47 patients (52%) were supported with vasoactive agents, while 43 (48%) were also supported with another device. The most common etiology of shock was acute on chronic heart failure (50, 56%), followed by acute myocardial infarction (22, 24%), and postcardiotomy (17, 19%). Overall, 69 patients (77%) survived to device removal, and 57 (65%) survived to hospital discharge. One-year survival was 54%. Neither etiology of heart failure nor device strategy was associated with 30-day or 1-year survival. On multivariable modeling, the number of vasoactive medications prior to device implantation was strongly associated with 30-day mortality (hazard ratio 1.94 [1.27-2.96], P < 0.01). Surgical Impella placement was associated with a significant decreased need for vasoactive infusions (P < 0.01) and decreased acidosis (P = 0.01). Conclusions Surgical Impella support for patients in acute cardiogenic shock is associated with lower vasoactive medication use, improved hemodynamics, increased end-organ perfusion, and acceptable morbidity and mortality.
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Affiliation(s)
- Timothy J. George
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
| | - Jenelle Sheasby
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
| | - J. Michael DiMaio
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
| | - Nitin Kabra
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
| | - David A. Rawitscher
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
| | - Aasim Afzal
- Department of Advanced Heart Failure and Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital – Plano, Plano, Texas
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20
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Bertolin S, Maj G, Cavozza C, Cardinale A, Pullara A, Audo A, Pappalardo F. Impella 5.0/5.5 Implantation via Innominate Artery: Further Expanding the Opportunities for Temporary Mechanical Circulatory Support. J Clin Med 2022; 11:jcm11195917. [PMID: 36233784 PMCID: PMC9570778 DOI: 10.3390/jcm11195917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
When axillary/subclavian arteries are not suitable because of size or anatomy, alternative access for the Impella pump 5.0/5.5 via the innominate artery allows circulatory support and eventually de-escalation from VA-ECMO to isolated left-side support. Moreover, less invasive surgery without the need to open the pericardium reduces the risk of RV dysfunction and bleeding. Finally, upper body strategies allow early rehabilitation during support, which is associated with improved survival in cardiogenic shock.
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Affiliation(s)
- Stephanie Bertolin
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
- Correspondence: ; Tel.: +39-3408503947
| | - Giulia Maj
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
| | - Corrado Cavozza
- Department of Cardiac Surgery, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
| | - Astrid Cardinale
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
| | - Alberto Pullara
- Department of Cardiology, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
| | - Andrea Audo
- Department of Cardiac Surgery, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Via Venezia, 16, 15121 Alessandria, Italy
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21
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Panuccio G, Neri G, Macrì LM, Salerno N, De Rosa S, Torella D. Use of Impella device in cardiogenic shock and its clinical outcomes: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2022; 40:101007. [PMID: 35360892 PMCID: PMC8961185 DOI: 10.1016/j.ijcha.2022.101007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/15/2022] [Indexed: 12/19/2022]
Abstract
Introduction Cardiogenic shock (CS) is a life-threatening condition and mechanical circulatory support (MCS) might exert a relevant impact on its clinical course. Among MCS devices, Impella is very promising. Yet, its usefulness is still debated. We performed a meta-analysis of all studies evaluating the clinical impact of Impella in CS. Methods All studies including patients with CS and treated with Impella were included. The primary endpoint was short-term mortality. Secondary endpoints were vascular access complications and major bleeding. Data synthesis was obtained using random-effects metanalysis. Results Thirty-three studies and 5204 patients were included. Short-term mortality was 47%. Meta-regression analysis showed that patients age (p = 0.01), higher support level (p = 0.004) and pre-PCI insertion (p < 0.001) were significant moderators for the primary endpoint. Vascular access complications were registered in 6.4% of cases, whereas age (p = 0.05) and diabetes (p = 0.007) were significant predictors. Major bleeding occurred in 16.4% of patients. Meta-analysis of the subgroup of studies comparing Impella to IABP showed no significant difference in short-term mortality (RR = 1.08, p = 0.45), while rates of vascular access complications (p < 0.001) or major bleeding (p < 0.001) were significantly higher with Impella. Subgroup and metaregression analyses showed that these results were influenced by lower adoption rates of higher degree of MCS support (p = 0.003), and by higher vascular complications rates (p = 0.014). Conclusions Our results suggest that the choice of adequate device size, careful patients selection and optimal timing of MCS initiation are key to clinical success with Impella in CS. Large prospective studies are mandatory to confirm these results deriving from retrospective studies.
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Affiliation(s)
- Giuseppe Panuccio
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Neri
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Lucrezia Maria Macrì
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nadia Salerno
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Daniele Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
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22
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Coyan G, Anand N, Imran M, Gomez H, Ramanan R, Murray H, Sanon S, Yoon P, Kaczorowski D, Bonatti J. ECMO and Impella Support Strategies as a Bridge to Surgical Repair of Post-Infarction Ventricular Septal Rupture. Medicina (B Aires) 2022; 58:medicina58050611. [PMID: 35630028 PMCID: PMC9146080 DOI: 10.3390/medicina58050611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.
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Affiliation(s)
- Garrett Coyan
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.); (M.I.); (P.Y.); (D.K.)
| | - Neesha Anand
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (N.A.); (H.G.); (R.R.); (H.M.)
| | - Mahnoor Imran
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.); (M.I.); (P.Y.); (D.K.)
| | - Hernando Gomez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (N.A.); (H.G.); (R.R.); (H.M.)
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (N.A.); (H.G.); (R.R.); (H.M.)
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; (N.A.); (H.G.); (R.R.); (H.M.)
| | - Saurabh Sanon
- Division of Cardiology, Department of Medicine, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Pyongsoo Yoon
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.); (M.I.); (P.Y.); (D.K.)
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.); (M.I.); (P.Y.); (D.K.)
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; (G.C.); (M.I.); (P.Y.); (D.K.)
- Correspondence:
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