The Current Use of Impella 2.5 in Acute Myocardial Infarction Complicated by Cardiogenic Shock: Results from the USpella Registry

Abstract

ObjectivesTo evaluate the periprocedural characteristics and outcomes of patients supported with Impella 2.5 prior to percutaneous coronary intervention (pre-PCI) versus those who received it after PCI (post-PCI) in the setting of cardiogenic shock (CS) complicating an acute myocardial infarction (AMI).BackgroundEarly mechanical circulatory support may improve outcome in the setting of CS complicating an AMI. However, the optimal timing to initiate hemodynamic support has not been well characterized.MethodsData from 154 consecutive patients who underwent PCI and Impella 2.5 support from 38 US hospitals participating in the USpella Registry were included in our study. The primary end-point was survival to discharge. Secondary end-points included assessment of patients’ hemodynamics and in-hospital complications. A multivariate regression model was used to identify independent predictors for mortality.ResultsBoth groups were comparable except for diabetes (P = 0.02), peripheral vascular disease (P = 0.008), chronic obstructive pulmonary disease (P = 0.05), and prior stroke (P = 0.04), all of which were more prevalent in the pre-PCI group. Patients in the pre-PCI group had more lesions (P = 0.006) and vessels (P = 0.01) treated. These patients had also significantly better survival to discharge compared to patients in the post-PCI group (65.1% vs.40.7%, P = 0.003). Survival remained favorable for the pre-PCI group after adjusting for potential confounding variables. Initiation of support prior to PCI with Impella 2.5 was an independent predictor of in-hospital survival (Odds ratio 0.37, 95% confidence interval: 0.17–0.79, P = 0.01) in multivariate analysis. The incidence of in-hospital complications included in the secondary end-point was similar between the 2 groups.ConclusionsThe results of our study suggest that early initiation of hemodynamic support prior to PCI with Impella 2.5 is associated with more complete revascularization and improved survival in the setting of refractory CS complicating an AMI.

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology–Association Canadienne de Cardiologie d'intervention)∗

“…For cardiogenic shock, a support device should be inserted as soon as possible, particularly if initial attempts with fluid resuscitation and pharmacologic support fail to show any significant hemodynamic benefit, and before PCI. 110 Early initiation of MCS support can mitigate the consequences of systemic hypoperfusion, worsening ischemia, and declining cardiac function. Hemodynamic evaluation and monitoring with right heart catheterization is helpful in most cases.…”

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

“…255 In the USpella registry of patients with CS treated with Impella devices before PCI, MCS placement resulted in improved survival to hospital discharge, even after adjustment for potential confounding variables. 256 For the iVAC and HeartMate Percutaneous Heart Pump, trial results are not currently available. More complete descriptions of commonly used percutaneous MCS devices can be found in Supplemental Table 6.…”

“…256,257 A common issue related to peripheral insertion is the resulting increase in LV afterload, which may lead to inadequate unloading of the LV. In these cases, combining veno-arterial ECMO with IABP, Impella support, atrial septostomy, or other venting maneuvers may help to achieve more complete LV unloading.…”

2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American heart assocation, the cardiological society of India, and sociedad latino Americana de cardiologia intervencion; Affirmation of value by the canadian association of interventional cardiology–association canadienne de cardiologie d'intervention)

“…For cardiogenic shock, a support device should be inserted as soon as possible, particularly if initial attempts with fluid resuscitation and pharmacologic support fail to show any significant hemodynamic benefit, and before PCI [110]. Early initiation of MCS support can mitigate the consequences of systemic hypoperfusion, worsening ischemia, and declining cardiac function.…”