Impella 5.0 Support in INTERMACS II Cardiogenic Shock Patients Using Right and Left Axillary Artery Access

Abstract

The catheter-based Impella 5.0 left ventricular assist device (LVAD) is a powerful and less invasive alternative for patients in cardiogenic shock. The use of this device as a primary mechanical circulatory support strategy in INTERMACS II patients should be evaluated. From April 2014 to August 2014, eight Impella 5.0 devices were implanted in seven patients via the axillary artery access (six right and two left). We analyzed the outcome of the four patients in whom the Impella 5.0 device was implanted for the purpose of primary stabilization of cardiogenic shock (INTERMACS II). The remaining three patients had a contraindication for a permanent LVAD and received the device for prolonged weaning from extracorporeal life support (ECLS) system. The implantation of the Impella 5.0 was technically successful in all patients and resulted in the stabilization of the clinical situation. All four patients could be bridged to a long-term device (n = 3) or to cardiac recovery (n = 1). In one patient, 2 days of ECLS support was necessary because of pump thrombosis after 31 days of Impella 5.0 support. One patient with bronchopneumonia had the Impella 5.0 exchanged from the right to the left axillary artery after 22 days of support because of the progressive loss of purge flow and the need for longer bridging to a permanent LVAD. The last patient was supported for giant-cell myocarditis for 22 days and bridged to cardiac recovery. All patients were transferred to the intensive care unit with the Impella device in place. In INTERMACS II situations, the implantation of the Impella 5.0 via the right or left axillary access allowed additional time for decision making. Early patient mobilization, including walking with the Impella device in place, optimized the conditions for either weaning or the implantation of a permanent LVAD. This novel technique of left axillary approach leads to more flexibility in the case of anatomical- or device-related contraindications to right-side access, or when the device needs to be exchanged while continuous support is necessary.

Impella 5.0 as a Second‐Line Mechanical Circulatory Support Strategy After Extracorporeal Life Support

“…The surgical technique of right axillary artery side graft anastomosis as an access for Impella 5.0 implantation has been described by Sassard et al . We described the use of the Impella 5.0 as primary MCS therapy in a small group of INTERMACS II patients with favorable results . INTERMACS I patients are treated with percutaneous ECLS implantation at our center.…”

“…During this period 13 Impella 5.0 and 1 Impella CP devices were implanted in 13 patients, and all implantations were performed via the axillary artery. We published the outcome of the first four patients in whom the Impella device had been implanted for the purpose of stabilizing the INTERMACS II cardiogenic shock situations . This analysis focuses on the eight implantations, which were performed as a second‐line procedure after ECLS.…”

“…During general anesthesia, the axillary artery below the clavicle was exposed via a skin incision. Systemic administration of heparin was carried out, aiming for an ACT>220 s. The exact operative technique was described earlier .The ECLS was surgically removed during the Impella 5.0 implantation in six patients and was left in place due to right ventricular and pulmonary dysfunction in two patients for 3 and 5 days, respectively.…”

“…Those patients were switched to a HeartMate II (Thoratec Corp., Pleasanton, CA, USA) LVAD after 12 and 25 days of Impella 5.0 support. The operative technique was described earlier . The long‐term follow‐up of all patients was conducted through regular visits at our ventricular assist and heart failure outpatient clinic.…”

“…Pozzi et al also described its use as a temporary bridge to long‐term left ventricular mechanical circulatory assistance, with an 80% success rate after permanent LVAD implantation . We described the use of Impella 5.0 in INTERMACS II situations with a 100% hospital discharge rate and 25% primary weaning from the Impella .…”