Prophylactic Impella CP versus VA-ECMO in Patients Undergoing Complex High-Risk Indicated PCI

Abstract

Objectives. To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Background. To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand. Methods. In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated. Results. A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22 ). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59 ). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22 ) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference ( p = 0.48 ). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09 ). Conclusions. In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.

Impella-Supported Optical Coherence Tomography-Guided Aggressive Rotational Atherectomy for Heavily Calcified Lesions in Left Main Trunk Bifurcation in a Patient with Severe Left Ventricular Systolic Dysfunction

“…As a result of this improvement in coronary circulation, Impella may reduce the risk of the no-reflow phenomenon during rotational atherectomy, which would improve postoperative cardiac function. On the other hand, another powerful circulatory assist device, venoarterial extracorporeal membrane oxygenation (VA-ECMO), increases the myocardial oxygen demand by increasing left ventricular afterload and wall stress; and as a result, observational studies have reported worse outcomes with circulatory assistance with VA-ECMO compared with impellers in PCI in CHIPs [ 10 ].…”

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

“…Lastly, a meta-analysis that comprised 41 patients undergoing high-risk PCI, demonstrated no difference in the outcomes when using prophylactic Impella versus VA-ECMO in patients undergoing high-risk PCI [ 32 ]. Therefore, the use of VA-ECMO in high-risk PCI has been demonstrated to have good results, although more research is necessary to confront it with other cardioprotective devices [ 18 ].…”

“…Although these devices and approaches have shown some promising results and are currently widely used for treating other conditions such as the use of VA-ECMO in respiratory failure, their uses in treating or preventing hemodynamic alterations in regard to cardiac surgery or percutaneous interventions still bear some important adverse effects that do not permit diminish of mortality in high-risk patients undergoing cardiac surgery or percutaneous interventions [ 12 , 13 , 14 , 15 , 16 ]. Therefore, while the use of one device over another in terms of efficacy remains controversial, further research must be conducted to assess their potential in different settings, whether that involves a single device or a combination of several [ 17 , 18 , 19 , 20 , 21 ]. Moreover, research into new strategies and targets such as transcutaneous vagus stimulation and supersaturated oxygen therapy, among others, that are being developed in order to reduce the mortality rate among high-risk patients undergoing cardiac surgery is needed [ 22 , 23 ].…”

Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review

“…VA-ECMO can also be used for assistance in high-risk PCI [41]. Scarce data show promising results in performing high-risk PCI with the prophylactic use of VA-ECMO [42]. However, the sample size is small, and prophylactic VA-ECMO implantation prior to high-risk PCI is far from clinical practice in most hospitals.…”