Impella to Unload the Left Ventricle During Peripheral Extracorporeal Membrane Oxygenation

Abstract

Peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) for acute cardiac failure reestablishes normal oxygen delivery and perfusion. However, VA ECMO can be limited by insufficient ventricular unloading, resulting in thrombus formation and pulmonary edema. Impella 2.5 has been used to unload the left ventricle and provide hemodynamic support during acute heart failure. We present our experience of the Impella 2.5 as an adjunct for left ventricular unloading during peripheral VA ECMO support and as a bridge for the HeartMate II left ventricular assist device (LVAD). An Impella 2.5 was placed in patients who were on peripheral VA ECMO with evidence of left ventricular distension. Patients who were candidates for heart transplant were transitioned to the HeartMate II LVAD. Five patients on VA ECMO with ventricular distension underwent Impella 2.5 implantation, resulting in a decreased left ventricular end-diastolic diameter as measured by echocardiography (7.8 ± 1.4 vs. 6.2 ± 0.8 cm, p = 0.001). Four patients were subsequently transitioned to the HeartMate II LVAD after restoration of end-organ function. Impella 2.5 is a safe means to unload the left ventricle while on peripheral VA ECMO to prevent left ventricle thrombus formation and worsening pulmonary edema in patients transitioning to a HeartMate II LVAD.

Successful Use of Surgically Placed Impella 5.0 and Central Extracorporeal Membrane Oxygenation Circuit in a Patient with Postcardiotomy Shock

“…7 Our experience is consistent with other authors' observations that the device helps to directly unload the LV during VA ECMO support. 8 In addition, Impella use can be continued for full hemodynamic support after the central ECMO circuit is removed.…”

“…6 The devices have also been successfully used for LV decompression after percutaneous placement during peripheral VA ECMO. 7 We report our direct aortic placement of the Impella 5.0 in conjunction with centrally cannulated VA ECMO. …”

Catastrophic Left Ventricular Thrombosis Complicating Extra-corporeal Membrane Oxygenation: A Case Report

“…Additionally, an indirect LV unloading with intra-aortic balloon pump has been reported with variable success in VA-ECMO patients with partially preserved cardiac contractility (Doll et al, 2004). Finally, very promising possibility is adding Impella device that represents an alternative option to support antegrade flow from LV to aorta (Cheng et al, 2013), however it is not routinely available particularly due to its cost. Nevertheless, due to the insufficient data from clinical trials it is not clear which venting method is superior to another and its effect on mortality also remains unknown (Meani et al, 2017).…”

What is extracorporeal cardiopulmonary resuscitation?

“…To the best of our knowledge, even if no studies have compared different strategies of ECMO flow regulation after cardiac arrest (hyperflow, normal flow, partial assistance), we strongly advise that the opportunity of setting the pump flow to values allowing for a rapid lactate clearance, restoration of urine output, resolution of metabolic acidosis should be carefully considered (28). The existence of effective systems of percutaneous LV venting should give the response to the case of profound cardiac depression and LV distension by a high, ECMO-dependent, afterload (29)(30)(31).…”