EC-VAD: Combined Use of Extracorporeal Membrane Oxygenation and Percutaneous Microaxial Pump Left Ventricular Assist Device

Akanni, O.; Takeda, Koji; Truby, Lauren K.; Kurlansky, Paul; Chiuzan, Codruța; Han, Jiho; Topkara, V.K.; Yuzefpolskaya, M.; Colombo, P.C.; Karmpaliotis, Dimitrios; Moses, Jeffery W.; Naka, Yoshifumi; Garan, A.R.; Kirtane, Ajay J.; Takayama, Hiroo

doi:10.1097/mat.0000000000000804

Cited by 52 publications

(23 citation statements)

References 22 publications

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“…In our selected population (patients eligible to both type of devices), IMPELLA ® devices were used in less severe patients as illustrated by a higher baseline LVEF and lower lactate level. All-cause 30-day and 6-month mortality rates were 46.9% and 52.3% respectively in the overall population and comparable with previous literature [11][12][13][14][15][16][17]. In the univariate analysis, VA-ECMO tends to be associated with better outcomes (not significant).…”

Section: Discussionsupporting

confidence: 86%

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IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Schurtz

Rousse

Saura³

et al. 2021

JCM

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Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

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Section: Discussionsupporting

confidence: 86%

“…To date, head-to-head comparison of IMPELLA ® versus VA-ECMO is limited since only a few studies focused on this topic in the literature [11][12][13][14][15][16][17]. In summary, all of these show similar outcomes between groups.…”

Section: Discussionmentioning

confidence: 99%

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Schurtz

Rousse

Saura³

et al. 2021

JCM

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“…The Impella provides multiple opportunities for treatment including left ventricular unloading, as compared with increased afterload in ECMO therapy and it benefits as a bridge to recovery or destination therapy. These findings have been supported by multiple studies that has compared the use of VA ECMO with Impella and VA ECMO patients alone [ 7 , 8 ]. In patients with cardiogenic shock, the “ECPELLA” (ECMO and Impella) was associated with significant decreases in central venous pressure, pulmonary pressures and vasoactive medication requirements as compared to on VA ECMO [ 7 , 8 ].…”

Section: Discussionmentioning

confidence: 54%

“…These findings have been supported by multiple studies that has compared the use of VA ECMO with Impella and VA ECMO patients alone [ 7 , 8 ]. In patients with cardiogenic shock, the “ECPELLA” (ECMO and Impella) was associated with significant decreases in central venous pressure, pulmonary pressures and vasoactive medication requirements as compared to on VA ECMO [ 7 , 8 ]. In addition, the use of ECPELLA was associated with greater ECMO weaning and bridging to permanent therapies [ 9 ].…”

Section: Discussionmentioning

confidence: 54%

The role of the axillary Impella 5.0 device on patients with acute cardiogenic shock

Tarabichi

Ikegami

Russo

et al. 2020

J Cardiothorac Surg

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Background: Acute cardiogenic shock is associated with high mortality rates. The Impella device is a microaxial left ventricular assist device that can be inserted through the axillary artery. The purpose of our study is to determine the role of the Axillary Impella devices on patients with acute cardiogenic shock. Methods: A retrospective chart review was conducted to identify patients who underwent Axillary Impella device placement for acute cardiogenic shock from January 1st, 2014 to September 30th, 2018 at a single institution. Inpatient records were examined to determine duration of device, length of stay (LOS), postoperative complications, and 30-day in-hospital mortality. Results: A total of 40 patients, who were primarily men (N = 29) with a mean age of 61.2 ± 10.7 years old, underwent Axillary Impella placement for cardiogenic shock. The primary reasons for implant were (1) required upgraded support from an Impella CP or intra-aortic balloon pump (iabp) to Impella 5.0, (2) to treat left ventricular (LV) distention for patients on extracorporeal mechanical oxygenation (ECMO), and (3) to provide longer term support and allow for mobilization of the patients in whom a device was already indwelling. Twenty-three of the patients had previous devices already in place including a Femoral Impella CP device or an iabp and 9 patients were on ECMO support. The duration of the device was 21.05 ± 17 days with the LOS of 40.8 ± 28 days for those patients. Seventeen of the patients went on to additional surgery including (1) Heartmate 3 device placement (N = 6), (2) other cardiac procedures such as surgical revascularization (N = 9), and orthotopic heart transplantation (N = 2). A total of 21 patients of the 40 (52%) died during their hospitalization with 7 patients (17%) having complications related to the Impella device. These complications included right arm ischemia or neuropathy (N = 3) and Impella malfunction requiring device replacement (N = 4). The majority of these devices were placed in the right axillary artery (N = 38) versus the left axillary artery (N = 2). Conclusions: A total of 58% (N = 23) of the study patients had previous mechanical support and 23% (N = 9) were on ECMO demonstrating the severity of disease and accounting for the high mortality. The Axillary Impella device allows for a minimally invasively placed device that is durable with a mean duration of 3 weeks. The Axillary artery Impella 5.0 provides upgraded full cardiac support while allowing for mobilization of the patient. In addition, it treats LV distention in patients on ECMO while avoiding sternotomy. Finally, the Axillary Impella provides time for decision making for explant, additional therapy with either long-term devices or orthotopic heart transplant.

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“…VA-ECMO. On full mechanical circulatory support, the hemodynamic status improved, and both systems were explanted after 48 h. Many centers are now moving toward the adoption of Impella as bailout for weaning and to unload the ventricle during VA-ECMO even if many warnings have been expressed regarding the risks to add more complexity to the management of an already complex patient [77,78]. Figure 8 shows the pathophisiology of Left Ventricle distention due to ECMO (Figure 8-1) and the effects of adding Impella during ECMO (Figure 8-2).…”

Section: Differences Between Atrial and Ventricular Unloadingmentioning

confidence: 99%

Flow Optimization, Management, and Prevention of LV Distention during VA-ECMO

Amarelli¹,

Musumeci²,

Loforte³

et al. 2019

Advances in Extra-Corporeal Perfusion Therapies

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Cardiogenic shock (CS) still carries an unacceptably high mortality (30-60%), despite several therapeutic approaches; the SHOCK II trial questioned the benefit of intra-aortic balloon pump (IABP), while IMPRESS and CULPRIT-SHOCK trials confirmed heterogeneity in disease spectrum and patient selection for acute myocardial infarction-related CS requiring acute mechanical circulatory support (AMCS). The heterogeneity of devices employed as AMCS, including temporary micro-axial flow pumps (Impella), percutaneous bypass (TandemHeart), and extracorporeal life support (VA-ECMO), contributed to the actual dramatic scenario, where CS is defined clinically rather than hemodynamically. To date, the role of VA-ECMO is emerging as rapid strategy to mitigate mortality rates of severe refractory states, despite the lack of data regarding the best practices of management and flows control. VA-ECMO's flow represents the "dose" of treatment and higher flows are less tolerated percutaneously requiring, to prevent deleterious pulmonary edema and ventricular distention, additional approaches such as pulmonary, left atrial, or left ventricular unloading. Any efforts have to be directed to (1) determine adequate management of patients on VA-ECMO, (2) define the safer duration of VA-ECMO support, and (3) establish algorithms and techniques to predict and obtain stable weaning from ECMO or ensure fast transition to durable VAD and/or heart transplant.

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EC-VAD: Combined Use of Extracorporeal Membrane Oxygenation and Percutaneous Microaxial Pump Left Ventricular Assist Device

Cited by 52 publications

References 22 publications

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

The role of the axillary Impella 5.0 device on patients with acute cardiogenic shock

Flow Optimization, Management, and Prevention of LV Distention during VA-ECMO

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