Increased and continuous coronary arterial flow was induced by LV uncoupling condition using combined treatment of a microaxial heart pump and venoarterial extracorporeal membrane oxygenation

Abstract

An emerging therapeutic modality, ECPELLA, which combines a transvalvular microaxial left ventricular (LV) assist device, Impella, and venoarterial membrane oxygenation (VA‐ECMO), has been applied for patients with refractory cardiogenic shock. During ECPELLA support, VA‐ECMO increases the LV load, whereas the Impella reduces the LV load. Studies reported that coronary perfusion is influenced by LV unloading conditions, and the effective degree of LV unloading to increase the coronary perfusion on ECPELLA support remains to be determined. Here, we reported a cardiogenic shock case whose coronary arterial flow was assessed by transesophageal echocardiography during ECPELLA support. The left anterior descending coronary artery (LAD) peak blood flow velocity and the velocity time integral (VTI) were not significantly increased when blood was ejected from the LV (partial LV unloading). When the LV blood ejection was completely bypassed by Impella confirmed by non‐pulsatile aortic pressure with significantly reduced LV pressure with no aortic valve opening (LV uncoupling: no blood ejection from the LV), both peak velocity and VTI of the LAD were markedly increased and the blood flow became continuous throughout the cardiac cycle. Our case suggests that the coronary arterial flow in the injured myocardium is sensitive to degrees of LV unloading on ECPELLA support.

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

“…We have previously reported a case of increased coronary arterial flow by LV uncoupling (total LV support) by ECPELLA in which reduced arterial pulse pressure appeared to be associated with total LV support. 23 These results imply that superior clinical outcomes might be associated with both right (lower PAPI and CVP) and left ventricular unloading effects to reduce myocardial damage with higher total MCS flow compared to VA-ECMO. Saku at el.…”

Impact of Impella on Coronary Flow Assessed by Transthoracic Doppler Echocardiography

“…The Impella device is a percutaneous micro-axial continuous-flow pump that is used for patients with cardiogenic shock and left ventricular (LV) unloading [ 1 ]. Impella-assisted forward blood flow may increase coronary blood flow; however, only a few studies have investigated in vivo coronary flow with Impella support [ 2 ]. We present a case involving a patient with myocardial infarction and subsequent cardiogenic shock whose coronary blood flow in the left anterior descending artery (LAD), according to the support setting, was evaluated using transthoracic Doppler echocardiography during Impella weaning.…”

Impella Motor Current Amplitude Reflects the Degree of Left Ventricular Unloading under ECPELLA Support

“…3,4) Additionally, we have recently reported a case where coronary flow was influenced by the degree of LV unloading on ECPELLA support. 5) Thus, it is essential to assess the degree of LV unloading for subsequent LV recovery with ECPELLA support. A previous study in a canine model revealed that the LV pressure (LVP) indicated the degrees of LV unloading on Impella support.…”