Impact of left ventricular unloading using a peripheral Impella®-pump in eCPR patients

Variability in triggers for mechanical left ventricular unloading in VA-ECMO: A literature search

BACKGROUND

Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a means of supporting the lungs or the heart and lungs in patients with hemodynamic compromise that is refractory to conventional measures. VA-ECMO is most commonly deployed in a percutaneous fashion with femoral arterial and venous access. While VA-ECMO, particularly in a femoral-femoral configuration, provides both hemodynamic and ventilatory support, it also causes increased afterload on the left ventricle (LV) which in turn may result in LV distension (LVD). LV thrombus formation, ventricular arrhythmias, pulmonary edema, and pulmonary hemorrhage are clinical manifestations of LVD. LV unloading is a means of preventing LVD and its sequelae. If less invasive methods fail to achieve adequate LV unloading, invasive mechanical methods are pursued such as intra-aortic balloon pump counter-pulsation, atrial septostomy, surgical venting, left atrial cannulation, and percutaneous transvalvular micro-axial pump placement.

METHODS

We sought to review indicators of LVD, thresholds, and options for mechanical venting strategies. A Pubmed search was performed to identify current literature about LV unloading for VA ECMO. This was categorized and summarized to determine commonly reported thresholds for mechanical LV unloading.

RESULTS

Multiple physiologic and radiographic indicators were reported without uniformity. Common indicators included increased pulmonary artery catheter pressures, decreased Aortic Line Pulse Pressure, as well as multiple Echocardiographic, and radiographic indicators.

CONCLUSION

Although there has been significant interest in the topic, there is currently limited uniformity in thresholds for when to initiate and escalate mechanical LV unloading. While the method of LV unloading is an active area of investigation, the threshold for which to initiate invasive venting strategies is largely unexplored.

ECPella 5+ in Patients With Cardiogenic Shock: Potential for Improved Outcomes

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support (MCS) is a common treatment in patients with cardiogenic shock (CS) but is associated with high morbidity and mortality. The combination therapy of VA- ECMO and Impella (ECPella) results in better outcomes. Currently, multiple generations of Impella are available for use in ECPella, however limited data exist to compare devices. Here, we explored whether ECPella 5+ adds further benefit to patient outcomes. We reviewed published studies focused on ECPella in CS to summarize clinical outcomes specifically pertaining to ECPella 5+. Findings were compared to outcomes from a contemporary cohort of 10 patients admitted for cardiogenic shock and treated with ECPella 5+ between January 2022 and May 2023. We evaluated 84 studies published in Pubmed between January 2017 and October 2023. Of these, 24 articles were selected for full analysis. Use of ECPella 5+ increased over time, with more than 50% of patients receiving this configuration in studies published in 2023. Mortality rate for ECPella 5+ (reported in 5 of 24 studies) was 33% compared to 49% for all ECPella combinations. Mortality outcomes of our patient cohort were consistent with a rate of 30%. These findings suggest that Impella 5+ may further improve outcomes of ECPella. However, the interpretation is limited by the small sample size and the descriptive nature of the data. Further larger, prospective studies are needed to determine potential improvements in complication rates, VA-ECMO and inotropic therapy duration, and native heart recovery.

Left Ventricular Unloading With Surgically Implanted Microaxial Flow Pump in Patients on Venoarterial Membrane Oxygenation

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is applied for the treatment of cardiogenic shock. Concomitant left ventricular unloading (LVU) with a microaxial flow pump (mAFP) enables myocardial and pulmonary recovery and may overcome some of the limitations of VA-ECMO. The study included 145 cardiogenic shock patients, 89 (61.4%) of whom were treated with VA-ECMO alone (ECMO group), whereas 56 (38.6%) received LVU with a surgically implanted mAFP on top of VA-ECMO (ECMELLA group). After 2:1 propensity score matching, 30 day and 1 year survival was similar between the groups ( p = 0.62 and 0.68, respectively). In the subgroup analysis, patients who received mAFP in the first 2 hours after VA-ECMO implantation had an improved 30 day (hazard ratio [HR]: 0.45 [95% confidence interval {CI}: 0.23-0.88], p = 0.02) and 1 year survival (HR: 0.52 [95% CI: 0.28-0.97], p = 0.04). The rate of limb ischemia, hemorrhage, and renal replacement therapy were comparable between the propensity score-matched cohorts. Early LVU with a surgically implanted mAFP in patients on VA-ECMO improved short-and long-term survival.

Unveiling Baseline Clinical Divergence in VA ECMO vs. ECPELLA: Tailoring Treatment for Distinct Patient Profiles. A Systematic Review and Meta-analysis

OBJECTIVES

The benefit of combining multiple mechanical circulatory support (MCS) systems in patients with cardiogenic shock (CS) is debated. This review examines patient characteristics across studies to identify differences and assesses if patients with a higher-risk clinical profile receive Impella unloading.

DESIGN

A systematic review and meta-analysis was conducted to examine if there were significant differences in baseline clinical parameters among patients receiving MCS in addition to venoarterial extracorporeal membrane oxygenation (VA ECMO).

SETTING

A total of nine retrospective, three prospective, and two randomized controlled trials were included in this analysis.

PARTICIPANTS

The sample sizes ranged from 34 to 1,678 patients.

INTERVENTIONS

The outcomes were assessments of differences in baseline clinical characteristics and comorbidities among patients that received VA ECMO alone or VA ECMO with intra-aortic balloon pump (IABP) versus ECPella.

MEASUREMENTS AND MAIN RESULTS

ECPella patients showed a higher prevalence of coronary artery disease (65.0% v 34.6%, p < 0.0001), cardiac arrest before MCS implantation (63.1% v 52.7%, p < 0.0001), and ischemic CS (53.1% v 42.6%, p < 0.0001) compared with patients with VA ECMO alone. The comparison between ECPella and VA ECMO + IABP patients showed a higher prevalence of acute myocardial infarction-CS (53.1% v 39.0%, p < 0.0001), preimplantation cardiac arrest (63% v 49.3%, p < 0.0001), and extracorporeal cardiopulmonary resuscitation (25.8% v 20.0%, p = 0.0015). The inclusion of the two randomized controlled trials in the VA ECMO group increased the prevalence of comorbidities compared with the ECPella group.

CONCLUSIONS

Patients who received a combination of MCS and VA ECMO have a greater prevalence of comorbidities.

Survival after extracorporeal cardiopulmonary resuscitation for adolescent arrhythmogenic arrest: ECPella (extracorporeal membrane oxygenation with Impella®)-a case report

Background

The combined therapy with venoarterial extracorporeal membrane oxygenation and Impella (ECPella) has been shown to improve survival in acute cardiogenic shock (CS) in adult patient. Only three paediatric cases have been reported in a multicentre study.

Case summary

We present our case, the first described to our knowledge in the UK, of a 15-year-old adolescent of Afro-Caribbean descent, weight 75 kg, who received extracorporeal cardiopulmonary resuscitation (E-CPR) and ECPella implantation. The patient suffered a sudden cardiac arrest at home; his mother called for an ambulance that arrived within 10 min and commenced life support with a LUCAS device. He received three doses of adrenaline and three desynchronized shocks for an underlying rhythm of ventricular fibrillation (VF) after which return of spontaneous circulation was achieved. He was then transferred to his local hospital where he had another VF arrest with successful cardioversion and was then transferred to our institution where on arrival he had another VF arrest and received E-CPR and ECPella implantation under the institutional adult shock programme within 3 h of in-hospital cardiac arrest. Following weaning from ECPella, the patient underwent cardiac and brain magnetic resonance imaging and serial echocardiograms with complete recovery of ventricular function. After implantation of cardiac defibrillator, he was discharged home without neurological sequelae. He remains asymptomatic from a cardiac perspective, with a normal cardiac examination and with no neurological sequelae at 2-year follow-up.

Discussion

This is the first case description of ECPella use in a child in the UK and highlighted the importance of timely institution of E-CPR on survival benefit in fatal CS. The outcome success of post-resuscitation ECPella strategy in this adolescent was through collaborative interprofessional engagement of multiple supra-specialists within acute cardiology and critical care across paediatric and adult services and alignment with the institutional adult shock programme.

Different strategies in left ventricle unloading during venoarterial extracorporeal membrane oxygenation: A network meta-analysis

Background

Left ventricular (LV) overload is a frequent complication during VA-ECMO associated with poor outcomes. Many strategies of LV unloading have been documented but lack of evidence shows which is better. We conducted a network meta-analysis to compare different LV unloading strategies.

Methods

We searched databases for all published studies on LV unloading strategies during VA-ECMO. The pre-defined primary outcome was all-cause mortality.

Results

45 observational studies (34235 patients) were included. The Surface Under the Cumulative Ranking values (SUCRA) demonstrated that compared to no unloading strategy (15.4 %), IABP (73.8 %), pLVAD (60.8 %), atrial septostomy (51.2 %), catheter venting (48.8 %) were all associated with decreased all-cause mortality, in which IABP and pLVAD existed statistical significance. For secondary outcomes, no unloading group had the shortest VA-ECMO duration, ICU and hospital length of stay, and the lower risk of complications compared with unloading strategies. IABP was associated with reducing VA-ECMO duration, ICU and hospital length of stay, and the risk of complications (except for hemolysis as the second best) compared with other unloading strategies.

Conclusions

LV unloading strategies during VA-ECMO were associated with improved survival compared to no unloading, but the tendency to increase the risk of various complications deserves more consideration.

ECPELLA: Beyond a Left Ventricular Venting Strategy When to Unload the Left Ventricle and How to Decide

Left ventricular (LV) unloading has been shown to improve survival for patients requiring veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. A mortality benefit has been shown for ECMO and concomitant placement of a transcatheter unloading LV pump such as an Impella device (colloquially referred to as ECPELLA or ECMELLA) for patients resuscitated with VA ECMO after a short period of cardiac arrest. Despite the described benefit of LV unloading with VA ECMO for cardiopulmonary resuscitation, it remains unclear as to what criteria should be used and what other diagnostic and therapeutic adjuncts may be useful. We describe here the successful utilization of concomitant VA ECMO and Impella in a 43 year old male with acute heart failure and cardiac arrest. Distinguishing itself from the currently reported methods, our methodology incorporates transesophageal echocardiography (TEE) in the emergency department for rapid decision-making in addition to an automatic chest compression device, the Lund University Cardiac Assist System (LUCAS) device (Stryker, Portage, MI) as a bridge to LV unloading in a hybrid operating suite.

Cardiac Devices and Kidney Disease

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.

Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR.

DATA SOURCES

Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology).

STUDY SELECTION

Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist.

DATA EXTRACTION

Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model.

DATA SYNTHESIS

Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses.

CONCLUSIONS

ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.

The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival.

METHODS

From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters.

RESULTS

Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005).

CONCLUSION

In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.

Case report: Refractory cardiac arrest supported with veno-arterial-venous extracorporeal membrane oxygenation and left-ventricular Impella CP®-Physiological insights and pitfalls of ECMELLA

INTRODUCTION

To the best of our knowledge, this is the first case report which provides insights into patient-specific hemodynamics during veno-arterio-venous-extracorporeal membrane oxygenation (VAV ECMO) combined with a left-ventricular (LV) Impella® micro-axial pump for therapy-refractory cardiac arrest due to acute myocardial infarction, complicated by acute lung injury (ALI).

PATIENT PRESENTATION

A 54-year-old male patient presented with ST-segment elevation acute coronary syndrome complicated by out-of-hospital cardiac arrest with ventricular fibrillation upon arrival of the emergency medical service. As cardiac arrest was refractory to advanced cardiac life support, the patient was transferred to the Cardiac Arrest Center for immediate initiation of extracorporeal cardiopulmonary resuscitation (ECPR) with peripheral VA ECMO and emergency percutaneous coronary intervention using drug eluting stents in the right coronary artery. Due to LV distension and persistent asystole after coronary revascularization, an Impella® pump was inserted for LV unloading and additional hemodynamic support (i.e., "ECMELLA"). Despite successful unloading by ECMELLA, post-cardiac arrest treatment was further complicated by sudden differential hypoxemia of the upper body. This so called "Harlequin phenomenon" was explained by a new onset of ALI, necessitating escalation of VA ECMO to VAV ECMO, while maintaining Impella® support. Comprehensive monitoring as derived from the Impella® console allowed to illustrate patient-specific hemodynamics of cardiac unloading. Ultimately, the patient recovered and was discharged from the hospital 28 days after admission. 12 months after the index event the patient was enrolled in the ECPR Outpatient Care Program which revealed good recovery of neurologic functions while physical exercise capacities were impaired.

CONCLUSION

A combined mechanical circulatory support strategy may successfully be deployed in complex cases of severe cardio-circulatory and respiratory failure as occasionally encountered in clinical practice. While appreciating potential clinical benefits, it seems of utmost importance to closely monitor the physiological effects and related complications of such a multimodal approach to reach the most favorable outcome as illustrated in this case.

Impact of extracorporeal CPR with transcatheter heart pump support (ECPELLA) on improvement of short-term survival and neurological outcome in patients with refractory cardiac arrest – A single-site retrospective cohort study

Aim

Extracorporeal cardiopulmonary resuscitation (E-CPR) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest. Although VA-ECMO preserves end-organ perfusion, it may affect left ventricular (LV) recovery due to increased LV load. An emerging treatment modality, ECPELLA, which combines VA-ECMO and a transcatheter heart pump, Impella, can simultaneously provide circulatory support and LV unloading. In this single-site cohort study, we assessed impact of ECPELLA support on clinical outcomes of refractory cardiac arrest patients.

Method

We retrospectively reviewed 165 consecutive cardiac arrest patients, who underwent E-CPR by VA-ECMO with or without intra-aortic balloon pump (IABP) or ECPELLA from January 2012 to September 2021. We assessed 30-day survival rate, neurological outcome, hemodynamic data, and safety profiles including hemolysis, acute kidney injury, blood transfusion and embolic cerebral infarction.

Results

Among 165 E-CPR patients, 35 patients were supported by ECPELLA, and 130 patients were supported by conventional VA-ECMO with or without IABP. Following propensity score matching of 30 ECPELLA and 30 VA-ECMO patients, the 30-day survival (ECPELLA: 53%, VA-ECMO: 20%, p < 0.01) and favorable neurological outcome determined by the Cerebral Performance Category score 1 or 2 (ECPELLA: 33%, VA-ECMO: 7%, p < 0.01) were significantly higher with ECPELLA. Patients receiving ECPELLA also showed significantly higher total mechanical circulatory support flow and lower arterial pulse pressure for the first 3 days (p < 0.01) of treatment. There were no statistical differences in safety profiles between treatment groups.

Conclusion

ECPELLA may be associated with improved 30-day survival and neurological outcome in patients with refractory cardiac arrest.