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

Unoki, Takashi; Kamentani, Motoko; Nakayama, Tomoko; Tamura, Yudai; Konami, Yutaka; Suzuyama, Hiroto; Inoue, M.; Yamamuro, Megumi; Taguchi, Eiji; Sawamura, Tadashi; Nakao, Kōichi; Sakamoto, Tomohiro

doi:10.1016/j.resplu.2022.100244

Cited by 16 publications

(9 citation statements)

References 28 publications

(25 reference statements)

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“…Another known complication of ECPELLA support is haemolysis, which is caused by the high shear stress on the erythrocytes due to the small inlet and outlet of the Impella device [ 6 ]. Haemolysis rates are reported to be between 22 and 45% [ 8 , 14 , 18 , 19 ], which is comparable to our finding of 25%.…”

Section: Discussionsupporting

confidence: 90%

ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience

Balder,

Szymanski,

van Laake

et al. 2024

Neth Heart J

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Background In refractory cardiogenic shock, temporary mechanical support (tMCS) may be crucial for maintaining tissue perfusion and oxygen delivery. tMCS can serve as a bridge-to-decision to assess eligibility for left ventricular assist device (LVAD) implantation or heart transplantation, or as a bridge-to-recovery. ECPELLA is a novel tMCS configuration combining venoarterial extracorporeal membrane oxygenation with Impella. The present study presents the clinical parameters, outcomes, and complications of patients supported with ECPELLA. Methods All patients supported with ECPELLA at University Medical Centre Utrecht between December 2020 and August 2023 were included. The primary outcome was 30-day mortality, and secondary outcomes were LVAD implantation/heart transplantation and safety outcomes. Results Twenty patients with an average age of 51 years, and of whom 70% were males, were included. Causes of cardiogenic shock were acute heart failure (due to acute coronary syndrome, myocarditis, or after cardiac surgery) or chronic heart failure, respectively 70 and 30% of cases. The median duration of ECPELLA support was 164 h (interquartile range 98–210). In 50% of cases, a permanent LVAD was implanted. Cardiac recovery within 30 days was seen in 30% of cases and 30-day mortality rate was 20%. ECPELLA support was associated with major bleeding (40%), haemolysis (25%), vascular complications (30%), kidney failure requiring replacement therapy (50%), and Impella failure requiring extraction (15%). Conclusion ECPELLA can be successfully used as a bridge to LVAD implantation or as a bridge-to-recovery in patients with refractory cardiogenic shock. Despite a significant number of complications, 30-day mortality was lower than observed in previous cohorts.

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Section: Discussionsupporting

confidence: 90%

ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience

Balder,

Szymanski,

van Laake

et al. 2024

Neth Heart J

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“…Impella causes three main effects: increase in cardiac power output, increase in oxygen supply, and decrease in oxygen demand, which may explain the better survival rate compared with VA-ECMO alone during refractory cardiac arrest. Indeed, survival benefits with ECMELLA compared with VA-ECMO alone have recently been shown in observational studies and meta-analyses in patients with AMI-induced cardiogenic shock, while research on LV unloading during refractory cardiac arrest has only been emerging recently (19)(20)(21). As of now, there is a lack of RCTs showing a benefit of ECMELLA therapy in refractory cardiac arrest.…”

Section: Mortality After Ecprmentioning

confidence: 99%

“…Additionally, associations with improved survival have been shown in retrospective cohort studies, although with a relatively high risk of bias due to confounding (13)(14)(15)(16)(17)(18). In the field of refractory cardiac arrest, single-cohort studies suggested that an ECMELLA approach might be associated with better survival; however, RCTs targeting this question are lacking (19)(20)(21).…”

mentioning

confidence: 99%

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

Thevathasan,

Füreder,

Fechtner

et al. 2024

Critical Care Medicine

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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.

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“…The use of Impella 2.5 in CS was established during the past decade. It was expected that immediate initiation of Impella use from the acute phase of CS would result in a marked decrease in PCWP (i.e., decrease in left ventricular filling pressure), reduction in infarct size, and prevention of subsequent HF [ 14 – 16 ]. It was also reported that the combined use of Impella and VA-ECMO was associated with both right (i.e., lower pulmonary artery pulsatility index and central venous pressure [CVP]) and left ventricular unloading effects.…”

Section: Organ Systems and Organ-specific Management Optionsmentioning

confidence: 99%

“…It was also reported that the combined use of Impella and VA-ECMO was associated with both right (i.e., lower pulmonary artery pulsatility index and central venous pressure [CVP]) and left ventricular unloading effects. This approach reduced myocardial damage and increased the total mechanical circulatory support flow compared with VA-ECMO alone [ 14 ]. However, it was recently reported that, compared with VA-ECMO support alone, the combination of Impella and VA-ECMO in patients with CS was associated with an increased rate of complications, such as bleeding, need for renal replacement therapy, hemolysis, and limb ischemia [ 17 ].…”

Section: Organ Systems and Organ-specific Management Optionsmentioning

confidence: 99%

Organ dysfunction, injury, and failure in cardiogenic shock

et al. 2023

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Background Cardiogenic shock (CS) is caused by primary cardiac dysfunction and induced by various and heterogeneous diseases (e.g., acute impairment of cardiac performance, or acute or chronic impairment of cardiac performance). Main body Although a low cardiac index is a common finding in patients with CS, the ventricular preload, pulmonary capillary wedge pressure, central venous pressure, and systemic vascular resistance might vary between patients. Organ dysfunction has traditionally been attributed to the hypoperfusion of the organ due to either progressive impairment of the cardiac output or intravascular volume depletion secondary to CS. However, research attention has recently shifted from this cardiac output (“forward failure”) to venous congestion (“backward failure”) as the most important hemodynamic determinant. Both hypoperfusion and/or venous congestion by CS could lead to injury, impairment, and failure of target organs (i.e., heart, lungs, kidney, liver, intestines, brain); these effects are associated with an increased mortality rate. Treatment strategies for the prevention, reduction, and reversal of organ injury are warranted to improve morbidity in these patients. The present review summarizes recent data regarding organ dysfunction, injury, and failure. Conclusions Early identification and treatment of organ dysfunction, along with hemodynamic stabilization, are key components of the management of patients with CS.

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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

Cited by 16 publications

References 28 publications

ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience

ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience

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

Organ dysfunction, injury, and failure in cardiogenic shock

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