Simultaneous Venoarterial Extracorporeal Membrane Oxygenation and Percutaneous Left Ventricular Decompression Therapy with Impella Is Associated with Improved Outcomes in Refractory Cardiogenic Shock

Abstract

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for refractory cardiogenic shock; however, it is associated with increased left ventricular afterload. Outcomes associated with the combination of a percutaneous left ventricular assist device (Impella) and VA-ECMO remains largely unknown. We retrospectively reviewed patients treated for refractory cardiogenic shock with VA-ECMO (2014-2016). The primary outcome was all-cause mortality within 30 days of VA-ECMO implantation. Secondary outcomes included duration of support, stroke, major bleeding, hemolysis, inotropic score, and cardiac recovery. Outcomes were compared between the VA-ECMO cohort and VA-ECMO + Impella (ECPELLA cohort). Sixty-six patients were identified: 30 ECPELLA and 36 VA-ECMO. Fifty-eight percentage of VA-ECMO patients (n = 21) had surgical venting, as compared with 100% of the ECPELLA cohort (n = 30) which had Impella (±surgical vent). Both cohorts demonstrated relatively similar baseline characteristics except for higher incidence of ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) in the ECPELLA cohort. Thirty-day all-cause mortality was significantly lower in the ECPELLA cohort (57% vs. 78%; hazard ratio [HR] 0.51 [0.28-0.94], log rank p = 0.02), and this difference remained intact after correcting for STEMI and PCI. No difference between secondary outcomes was observed, except for the inotrope score which was greater in VA-ECMO group by day 2 (11 vs. 0; p = 0.001). In the largest US-based retrospective study, the addition of Impella to VA-ECMO for patients with refractory cardiogenic shock was associated with lower all-cause 30 day mortality, lower inotrope use, and comparable safety profiles as compared with VA-ECMO alone.

Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative

“…This was in lieu of comparable blood pressures, rates of cardiac arrest, and lactate levels. MCS has not been shown to improve survival in previous studies; however, these devices are used inconsistently among clinicians and used in a heterogeneous cohort of patients . In the absence of data from randomized control trials (RCT), the present analysis represents the highest survival reported in AMICS albeit with the limitations of an observational single arm study.…”

“…however, these devices are used inconsistently among clinicians and used in a heterogeneous cohort of patients. 3,5,7,[13][14][15] In the absence of data from randomized control trials (RCT), the present analysis represents the highest survival reported in AMICS albeit with the limitations of an observational single arm study. Therefore, in lieu of evidence from RCT, the authors believe it is reasonable for centers that have adopted MCS as a treatment in AMICS to implement the CPO is a simple calculation using the mean arterial pressure and multiplying it by the cardiac output and dividing by a constant of 451.…”

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

“…The use of Impella in combination with VA-ECMO (also known as ECPELLA/ECMELLA) has been shown to provide improved weaning and survival rates compared to ECMO alone strategy and to established risks scores [47][48][49][50]. The addition of a continuous flow vent reduces LV volumes and pressures.…”

Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review

“…Pulmonary edema and pulmonary artery pressures were reduced in both groups, and there were no significant differences between the 2 groups in 30-day survival, discharge from the intensive care unit, vascular complications, VA-ECMO decannulation, or transition to a durable left ventricular assist device. In contrast, Patel et al 87 retrospectively found a lower mortality in patients requiring VA-ECMO support for refractory cardiogenic shock who received an Impella device for left ventricular decompression compared with selective placement of a surgically placed vent. Only 21/36 (58%) of patients in the VA-ECMO § surgical vent group received mechanical left ventricular decompression, compared with 30/30 (100%) of patients in the VA-ECMO + Impella group.…”

“…Numerous case series describe the use of the Impella device, for left ventricular unloading in patients supported with VA-ECMO. Outcomes reported include a reduction in mortality, 36,87,88 pulmonary hypertension, and pulmonary edema. 89À92 However compared with VA-ECMO alone, there may be an increased incidence of hemolysis.…”