Circulatory Support with Extracorporeal Membrane Oxygenation and/or Impella for Cardiogenic Shock During Myocardial Infarction

Abstract

Temporary mechanical circulatory support (TCS) is recommended for patients with profound cardiogenic shock (CS). Extracorporeal membrane oxygenation (ECMO) and Impella are possible TCS devices, but the device choice and the implantation timing are not definitely established, specifically during acute myocardial infarction. We have analyzed the respective use of ECMO or Impella (2.5, CP, or 5.0) for CS following acute myocardial infarction, from a cohort of patients who underwent TCS within 72 hours after admission for emergency percutaneous coronary intervention (PCI) from January 2009 to April 2015. Among 88 TCS-treated patients, 42 had early TCS: 23 ECMO and 19 Impella. Cardiac management, including PCI, was similar between the two groups, but ECMO patients were sicker than Impella patients (higher blood lactate level at ICU admission, higher vasoactive-inotroic and ENCOURAGE scores before TCS implantation, p ≤ 0.02). Three patients (7%) have had TCS implantation before admission, but TCS was implanted mostly in cathlab (43%, 1 during PCI, 13 just after PCI) or soon after ICU admission (50%, n = 21). Modification of the initial TCS choice was required in 10 cases (24%) for assistance upgrading in case of Impella (n = 4) or for left ventricle unloading in case of ECMO (n = 6). Extracorporeal membrane oxygenation is the technique of choice in case of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise. Interestingly, the combination of both techniques may help to overcome the limits inherent to each device.

Extracorporeal life support in the multidisciplinary management of cardiogenic shock complicating acute myocardial infarction

“…Unfortunately, routine treatment with Impella CP was not associated with a reduction in 30‐day mortality compared with IABP in a randomized controlled trial involving 48 patients with severe shock complicating AMI . Therefore, Impella 5.0 seems an interesting option for more stable AMI patients developing cardiogenic shock while ECLS should be the treatment of choice in case of profound cardiogenic shock …”

“…33 Therefore, Impella 5.0 seems an interesting option for more stable AMI patients developing cardiogenic shock while ECLS should be the treatment of choice in case of profound cardiogenic shock. 34…”

A Review of percutaneous mechanical support devices and strategies

“…However, there are reports suggesting that extracorporeal membrane oxygenation is preferable in cases of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise, such as those who can still generate some native contribution to their cardiac output. Furthermore, the combination of both techniques, discussed later in this article, may help to overcome the limits inherent with each device (Mourad et al, 2017).…”

“…This potentially lengthened deployment time limits the 5.0's ability to be used as an acute salvage device. However, the Impella 5.0 is often successfully used as a device to upgrade from Impella CP, or as an avenue to uncouple from veno-arterial ECMO (Mourad et al, 2017;Moazzami et al, 2017).…”

Successful extracorporeal membrane oxygenation assisted revascularisation in a high-risk elderly patient refused surgical treatment

“…The use of extracorporeal life support in adult patients has increased dramatically during recent years (2). It is becoming more utilised for the treatment of cardiogenic shock related to an acute myocardial infarction (3). We herein report a case of an octogenarian patient with severely decreased left ventricular ejection fraction, severe mitral regurgitation, mild aortic and tricuspid valve insufficiency, and three-vessel disease.…”