Left Ventricular Unloading Before Reperfusion Promotes Functional Recovery After Acute Myocardial Infarction

Esposito, Michele; Zhang, Yali; Qiao, Xiaoying; Reyelt, Lara; Paruchuri, Vikram; Schnitzler, Gavin R.; Morine, Kevin; Annamalai, Shiva; Bogins, Courtney; Natov, Peter; Pedicini, Robert; Breton, Catalina; Mullin, Andrew; Mackey, Emily; Patel, Ayan R.; Rowin, Ethan J.; Jaffe, Iris Z.; Karas, Richard H.; Kapur, Navin K.

doi:10.1016/j.jacc.2018.05.034

Cited by 151 publications

(119 citation statements)

References 31 publications

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“…It consists of a miniaturised axial flow pump fitted onto a pigtail catheter, pumping blood from the left ventricle into the ascending aorta and providing a cardiac output of 2.5 L/min (Impella 2.5) and up to 4.0 L/min (Impella CP) 5 6. It actively unloads the left ventricle reducing the stroke-work and myocardial oxygen consumption, thereby providing cardioprotection and robust haemodynamic support 7–9…”

Section: Introductionmentioning

confidence: 99%

Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

et al. 2019

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ObjectiveWe investigated the benefit of Impella, a modern percutaneous mechanical support (pMCS) device, versus former standard intra-aortic balloon pump (IABP) in acute myocardial infarction complicated by cardiogenic shock (AMICS).MethodsThis single-centre, retrospective study included patients with AMICS receiving pMCS with either Impella or IABP. Disease severity at baseline was assessed with the IABP-SHOCK II score. The primary outcome was all-cause mortality at 30 days. Secondary outcomes were parameters of shock severity at the early postimplantation phase. Adjusted Cox proportional hazards models identified independent predictors of the primary outcome.ResultsOf 116 included patients, 62 (53%) received Impella and 54 (47%) IABP. Despite similar baseline mortality risk (IABP-SHOCK II high-risk score of 18 % vs 20 %; p = 0.76), Impella significantly reduced the inotropic score (p < 0.001), lactate levels (p < 0.001) and SAPS II (p =0.02) and improved left ventricular ejection fraction (p = 0.01). All-cause mortality at 30 days was similar with Impella and IABP (52 % and 67 %, respectively; p = 0.13), but bleeding complications were more frequent in the Impella group (3 vs 4 units of transfused erythrocytes concentrates due to bleeding complications, p = 0.03). Previous cardiopulmonary resuscitation (HR 3.22, 95% CI 1.76 to 5.89; p < 0.01) and an estimated intermediate (HR 2.77, 95% CI 1.42 to 5.40; p < 0.01) and high (HR 4.32 95% CI 2.03 to 9.24; p = 0.01) IABP-SHOCK II score were independent predictors of all-cause mortality.ConclusionsIn patients with AMICS, haemodynamic support with the Impella device had no significant effect on 30-day mortality as compared with IABP. In these patients, large randomised trials are warranted to ascertain the effect of Impella on the outcome.

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Section: Introductionmentioning

confidence: 99%

Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

et al. 2019

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“…Recent extensive animal studies showed that mechanical unloading of the left ventricle before coronary reperfusion limits the expression of proteolytic enzymes. This resulted in less cell decay, reduced infarction size and better haemodynamic performance [33]. A recent clinical trial also showed promising results when the Impella support was initiated before emergency PCI [34].…”

Section: Discussionmentioning

confidence: 99%

Haemodynamic efficacy of microaxial left ventricular assist device in cardiogenic shock: a systematic review and meta-analysis

et al. 2019

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The Impella percutaneous mechanical circulatory support device is designed to augment cardiac output and reduce left ventricular wall stress and aims to improve survival in cases of cardiogenic shock. In this meta-analysis we investigated the haemodynamic effects of the Impella device in a clinical setting. We systematically searched all articles in PubMed/ Medline and Embase up to July 2019. The primary outcomes were cardiac power (CP) and cardiac power index (CPI). Survival rates and other haemodynamic data were included as secondary outcomes. For the critical appraisal, we used a modified version of the U.S. Department of Health and Human Services quality assessment form. The systematic review included 12 studies with a total of 596 patients. In 258 patients the CP and/or CPI could be extracted. Our meta-anal-D.I.M. van Dort and K.R.A.H. Peij contributed equally to this manuscript. ysis showed an increase of 0.39 W [95% confidence interval (CI): 0.24, 0.54], (p = 0.01) and 0.22 W/m 2 (95% CI: 0.18, 0.26), (p < 0.01) for the CP and CPI, respectively. The overall survival rate was 56% (95% CI: 0.50, 0.62), (p = 0.09). The quality of the studies was moderate, mostly due to the presence of confounders. Our study suggests that in patients with cardiogenic shock, Impella support seems effective in augmenting CP(I). This study merely investigates the haemodynamic effectiveness of the Impella device and does not reflect the complete clinical impact for the patient. Review Article ConclusionOur meta-analysis shows that short-term MCS with the Impella device is effective in increasing CP and CPI. Despite successfully increased CP with Impella support, the mortality seems to be in line with the survival rate without Impella use.

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“…28 The mechanisms underlying this cardioprotective effect of primary unloading, and its impact of LV scar size were further explored by a seminal preclinical study by the same group. 22 In this study, male Yorkshire swine was subjected to either 90 minutes of mid-LAD occlusion followed by immediate reperfusion (primary reperfusion group) or 30 minutes of unloading before reperfusion (primary unloading group). Primary unloading increased the expression of genes associated with cellular respiration and mitochondrial integrity within the infarct zone, reduced activity levels of proteases known to degrade the cardioprotective cytokine, stromal-derived factor (SDF)-1a, limiting apoptosis in the infarct zone (Figure 1).…”

Section: Unloading-pre Clinical Datamentioning

confidence: 99%

Left ventricular unloading in ST‐elevation myocardial infarction without cardiogenic shock

Alkhouli

2020

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Left Ventricular Unloading Before Reperfusion Promotes Functional Recovery After Acute Myocardial Infarction

Cited by 151 publications

References 31 publications

Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

Haemodynamic efficacy of microaxial left ventricular assist device in cardiogenic shock: a systematic review and meta-analysis

Left ventricular unloading in ST‐elevation myocardial infarction without cardiogenic shock

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