Impact of preoperative Impella support on destination left ventricular assist device outcomes

Abstract

Background Although left ventricular assist device (LVAD) implantation is associated with improved heart failure survival, the impact of pre‐implantation Impella support on outcomes is unknown. We undertook this study to evaluate the impact of preoperative Impella support on LVAD outcomes. Methods We conducted a retrospective review of all Heartmate 3 LVAD implants. Primary stratification was by the need for preoperative Impella support with the 5.0/5.5 device. Longitudinal survival was assessed by the Kaplan–Meier method. Multivariable Cox proportional hazards regression models were developed to evaluate mortality. Secondary outcomes included changes in laboratory values during Impella support. Results From 2017 to 2021, 87 patients underwent LVAD implantation. Sixteen were supported with a single inotrope, 36 with dual inotropes, 27 with Impella, and 3 with extracorporeal membrane oxygenation (ECMO). When stratified by the need for Impella, there was no difference in survival at 30‐days (98.3 [88.2–99.8]% vs. 96.3 [76.5–99.5]%, p = .59), 1‐year (91.0 [79.8–96.2] vs. 74.9 [51.7–88.2], p = .10), or at 2 years (87.9 [74.3–94.5] vs. 74.9 [51.7–88.2], p = .15). On multivariable modeling, the need for preoperative Impella was not associated with an increased hazard of 1‐year (1.24 [0.23–6.73], p = .81) or 2‐year mortality (1.05 [0.21–5.19], p = .95). After 7 (5–10) days of Impella support, recipient creatinine (p < .01), creatinine clearance (p = .02), and total bilirubin (p = .053) improved and lactic acidosis resolved (p < .01). Conclusions Preoperative Impella support is not associated with increased short or long‐term mortality but is associated with improved renal and hepatic function as well as total body perfusion before LVAD implantation.

Patient Characteristics and Early Clinical Outcomes With Impella 5.5: A Systematic Review and Meta-Analysis

“…Vascular access was predominantly via the axillary artery (98.6% among patients reported, of which 96.9% were right axillary among 386 patients reported), whereas direct aortic access represented a minority of patients (0.8%). Rates of concomitant ECMO with Impella support were 24.7% of 661 patients in studies 7 and Salas De Armas et al 16 report outcomes with Impella support only among patients surviving to device explant. These studies were excluded from qualitative synthesis of early survival after device implant.…”

“…In another analysis, Salas De Armas et al 16 reported 14 patients with cardiac cachexia bridged with Impella 5.5 or 5.0 to durable left ventricular assist device (LVAD). George et al 7 reported 84 patients successfully bridged to durable LVAD with or without temporary MCS using Impella 5.5. Ohira et al 13 reported seven patients who were treated with an "ECPELLA" strategy (ECMO + Impella 5.5).…”

“…Thirteen studies were included in quantitative meta-analysis of early survival outcomes. The analyses by George et al 7 and Salas De Armas et al 16 were excluded as they reported only patients successfully bridged to durable LVAD.…”

Impella bridge to durable LVAD: A short run for a long slide

“…Newer devices supply as much as 5.5 L of forward flow allowing for excellent circulatory support in critical heart failure patients, although data on their use as bridge to LVAD is limited. This retrospective study by George et al 1 reviewed all Heartmate 3 patients at a single institution requiring preoperative inotropes either with or without tMCS in the form of a surgical Impella 5.0/5.5. The investigators found similar survival at 30 days, 1, and 2 years post LVAD implantation with multivariable analysis demonstrating no difference in 1-or 2-year survival in the Impella group.…”

“…This retrospective study by George et al 1 reviewed all Heartmate 3 patients at a single institution requiring preoperative inotropes either with or without tMCS in the form of a surgical Impella 5.0/5.5. The investigators found similar survival at 30 days, 1, and 2 years post LVAD implantation with multivariable analysis demonstrating no difference in 1‐ or 2‐year survival in the Impella group.…”