Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices-A Retrospective, Single-Centre Cohort Study

Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5

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.

The "via dialysis circuit" external bypass technique: External femoral to femoral bypass via dialysis circuit for antegrade perfusion of the ischemic limb

A 71-year-old woman with no relevant previous medical history presented to the emergency department with cardiopulmonary arrest due to extensive myocardial infarction. Veno-arterial extracorporeal life support (ECLS) was passed through the right common femoral artery (CFA), and an Impella CP® (16-F introduction sheath, Abiomed Inc., Danvers, MA, USA) was inserted from the left CFA. Although these mechanical devices provide powerful cardiac and organ support, an occlusive large-bore sheath may induce ischemic limb complications. Antegrade flow from the contralateral sheath was circulated through the ECLS circuit, showing the improvement of antegrade left SFA. Cardiac function improved after primary percutaneous coronary intervention, but when the ECLS was terminated, antegrade left limb flow declined. Hence, we bypassed the contralateral flow via the dialysis circuit and prevented limb ischemia.

Learning objective

Although an Impella® (Abiomed Inc., Danvers, MA, USA) is useful for assisting left ventricular cardiac function, its large-bore sheath sometimes disturbs the antegrade flow, resulting in ischemic limb complications. A novel yet simple technique that involves an external bypass through the superficial femoral artery to provide antegrade perfusion to the ipsilateral limb is hereby described.

The ongoing quest for the first total artificial heart as destination therapy

Many patients with end-stage heart disease die because of the scarcity of donor hearts. A total artificial heart (TAH), an implantable machine that replaces the heart, has so far been successfully used in over 1,700 patients as a temporary life-saving technology for bridging to heart transplantation. However, after more than six decades of research on TAHs, a TAH that is suitable for destination therapy is not yet available. High complication rates, bulky devices, poor durability, poor biocompatibility and low patient quality of life are some of the major drawbacks of current TAH devices that must be addressed before TAHs can be used as a destination therapy. Quickly emerging innovations in battery technology, wireless energy transmission, biocompatible materials and soft robotics are providing a promising opportunity for TAH development and might help to solve the drawbacks of current TAHs. In this Review, we describe the milestones in the history of TAH research and reflect on lessons learned during TAH development. We summarize the differences in the working mechanisms of these devices, discuss the next generation of TAHs and highlight emerging technologies that will promote TAH development in the coming decade. Finally, we present current challenges and future perspectives for the field.

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

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

Special Issue “New Perspectives in Cardiovascular Surgery”

In recent decades, cardiovascular surgery has been making great strides in the field of medicine [...]

Antithrombotic management for Impella® temporary ventricular assist devices: An analysis of an academic health-system experience

The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella^® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella^® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella^® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella^® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella^®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella^® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072-5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella^®.