Impact of left ventricular unloading using a peripheral Impella®‐pump in eCPR patients

Abstract

Background Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to increasing survival rates in selected patients. Additional left ventricular mechanical unloading, using a transfemoral micro‐axial blood pump (Impella® Denver, Massachusetts, USA), might improve patients’ outcomes. In this regard, we sought to investigate patients who suffered OHCA (out‐of hospital cardiac arrest) or IHCA (in‐hospital cardiac arrest) with subsequent eCPR via VA‐ECMO (veno‐arterial extracorporeal membrane oxygenation) and concomitant Impella® implantation based on survival and feasibility of ECMO weaning. Methods From January 2016 until December 2020, 108 patients underwent eCPR at our institution. Data prior to eCPR and early outcome parameters were analyzed comparing patients who were supported with an additional Impella® (2.5 or CP) (ECMO+Impella®, n = 18) and patients without additional (ECMO, n = 90) support during V‐A ECMO therapy. The primary endpoint was in‐hospital mortality; secondary endpoints were, among others: ECMO explantation, need for hemodialysis, stroke, and need for blood transfusions. Results Low‐flow time was significantly lower in the ECMO+Impella group (60 min vs. 55 min, p = .01). All‐cause mortality was significantly lower in the ECMO+Impella® group (82% vs. 56%, p = .01). The time of circulatory support was shorter in the ECMO cohort (2.0 ± 1.73 vs. 4.76 ± 2.88 p = .05). ECMO decannulation was significantly more feasible in patients with ECMO+Impella® (72% vs. 32%, p = .01). Patients treated with additional Impella® showed significantly more acute kidney injury with the need for dialysis (72% vs. 18%, p ≤ .01). Conclusion Concomitant Impella® support might positively influence survival and ECMO weaning in eCPR patients. Treatment‐associated complications such as the need for dialysis were more common in this highly selected patient group. Further studies with larger numbers are necessary to evaluate the clinical relevance of concomitant LV‐unloading in eCPR patients using an Impella® device.

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

“…Beneficial effect of ECPELLA on E-CPR patients has been recently reported by Gaisendrees et al in which ECPELLA significantly reduced all-cause mortality and improved VA-ECMO weaning rate. 13 In the present study, we found that ECPELLA support was associated with higher rate of VA-ECMO weaning and 30-day survival similar to the previous study. 13 Patients received ECPELLA support exhibited higher mean arterial pressure on MCS day 1; lower pulse pressure from MCS days 1 to 3; and a lower heart rate on MCS day 2.…”

“… 13 In the present study, we found that ECPELLA support was associated with higher rate of VA-ECMO weaning and 30-day survival similar to the previous study. 13 Patients received ECPELLA support exhibited higher mean arterial pressure on MCS day 1; lower pulse pressure from MCS days 1 to 3; and a lower heart rate on MCS day 2. However, VIS did not show difference between ECPELLA and VA-ECMO.…”

“…Gaisendrees et al also reported that rate of acute kidney injury requiring renal replacement therapy of ECPELLA support was higher compared to single VA-ECMO support. 13 In the current study, the incidence rate of acute kidney injury did not show statistical difference between ECPELLA and VA-ECMO. We speculate the difference between our results and their results could be due to ECPELLA initiation timing and higher total circulatory support achieved by ECPELLA in our institute.…”

“…We speculate the difference between our results and their results could be due to ECPELLA initiation timing and higher total circulatory support achieved by ECPELLA in our institute. 13. , 22.…”

“…Gaisendrees et al, described that ECPELLA timing was determined by levels of LV distension, blood retention within the LV cavity (spontaneous contraction by echocardiography), and pulmonary edema due to increased afterload by VA-ECMO. 13 In contract, we established ECPELLA support at the earliest time point immediately after the establishment of E-CPR to obtain a VA-ECMO perfusion index ≥ 2.2 L/min/m 2 preventing the aortic valve opening in which Impella was used to directly pump out the blood from the LV cavity increasing total MCS flow (total LV support) 15 Further studies are necessary whether reduction of acute kidney injury is associated with ECPELLA support timing, higher total circulatory support flow, and/or arterial perfusion pressure.…”