Impella-Induced Incessant Ventricular Tachycardia

Short-term percutaneous mechanical circulatory support: no promise without positioning!

Short-term percutaneous mechanical circulatory support by a micro-axial flow pump is increasingly used to support the left ventricle in cardiogenic shock. After a correct indication and placement, appropriate device management in the cardiac intensive care unit is vital to ensure optimal pump function and adequate haemodynamic support. A key element hereby is a correct percutaneous ventricular assist device (pVAD) position. This review explains how an optimal left-sided pVAD position can be achieved and maintained, focusing on the correct insertion depth and rotational angle. Useful imaging techniques, placement and replacement manoeuvres, and monitoring options through the console are discussed. The frequently encountered problem of mal-rotation towards the mitral valve, which may cause suction alarms, haemolysis, aortic regurgitation, and inadequate haemodynamic support, is explained. Finally, a practical bedside approach to assess pVAD position and discern suction alarms due to mal-positioning from haemodynamic problems is proposed.

Peripherally inserted concomitant surgical right and left ventricular support, the Propella, is associated with low rates of limb ischemia, with mortality comparable with peripheral venoarterial extracorporeal membrane oxygenation

BACKGROUND

Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia.

METHODS

This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively.

RESULTS

Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007).

CONCLUSION

Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.

A case of left ventricular free wall rupture after insertion of an IMPELLA® left ventricular assist device diagnosed by transesophageal echocardiography

Background

The IMPELLA® is a minimally invasive left ventricular assist device. We report a case in which transesophageal echocardiography (TEE) was useful in diagnosis of left ventricular rupture after IMPELLA® insertion.

Case presentation

A 75-year-old man presented to the emergency room with chest pain and underwent percutaneous coronary intervention for 100% stenosis of the left anterior descending branch #7. An IMPELLA® was inserted to stabilize the circulation, but hypotension persisted. Transthoracic echocardiography revealed increased pericardial effusion and suspicion of free wall left ventricular rupture, leading to emergency surgery. TEE revealed the IMPELLA® straying into the left ventricle apical wall and cardiac tamponade. Hemorrhage was observed from the thinning free wall and the tip of the IMPELLA® was palpable. The IMPELLA® was removed and the left ventricular wall was repaired.

Conclusions

The IMPELLA® requires implantation of the tip in the left ventricle, but it should be noted that a fragile ventricular wall can be easily perforated.

Cardiac Arrhythmias in Survivors of Sudden Cardiac Death Requiring Impella Assist Device Therapy

In this retrospective single-center trial, we analyze 109 consecutive patients (female: 27.5%, median age: 69 years, median left ventricular ejection fraction: 20%) who survived sudden cardiac death (SCD) and needed hemodynamic support from an Impella assist device between 2008 and 2018. Rhythm monitoring is investigated in this population and associations with hospital survival are analyzed. Hospital mortality is high, at 83.5%. Diverse cardiac arrhythmias are frequently registered during Impella treatment. These include atrial fibrillation (AF, 21.1%) and ventricular tachycardia (VT, 18.3%), as well as AV block II°/III° (AVB, 7.3%), while intermittent asystole (ASY) is the most frequently observed arrhythmia (42.2%). Nevertheless, neither ventricular nor supraventricular tachycardias are associated with patients' survival. In patients who experience intermittent asystole, a trend towards a fatal outcome is noted (p = 0.06). Conclusions: Mortality is high in these severely sick patients. While cardiac arrhythmias were frequent, they did not predict hospital mortality in this population. The hemodynamic support of the pump seems to counterbalance the adverse effects of these events.

The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges

Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient's specific hemodynamic profile appears to be the future of cardiogenic shock management.