Trends in Veno‐Arterial Extracorporeal Life Support With and Without an Impella or Intra‐Aortic Balloon Pump for Cardiogenic Shock

Abstract

Background Mechanical circulatory support devices, such as the intra‐aortic balloon pump (IABP) and Impella, are often used in patients on veno‐arterial extracorporeal life support (VA‐ECLS) with cardiogenic shock despite limited supporting clinical trial data. Methods and Results Hospitalizations for cardiogenic shock from 2016 to 2018 were identified from the National Inpatient Sample. Trends in the use of VA‐ECLS with and without an IABP or Impella were assessed semiannually. Multivariable logistic regression and general linear regression evaluated the association of Impella and IABP use with in‐hospital outcomes. Overall, 12 035 hospitalizations with cardiogenic shock and VA‐ECLS were identified, of which 3115 (26%) also received an IABP and 1880 (16%) an Impella. Use of an Impella with VA‐ECLS substantially increased from 10% to 18% over this period ( P <0.001), whereas an IABP modestly increased from 25% to 26% ( P <0.001). In‐hospital mortality decreased 54% to 48% for VA‐ECLS only, 61% to 58% for VA‐ECLS with an Impella, and 54% to 49% for VA‐ECLS with an IABP ( P <0.001 each). Most (57%) IABPs or Impellas were placed on the same day as VA‐ECLS. After adjustment, there were no differences in in‐hospital mortality or length of stay with the addition of an IABP or Impella compared with VA‐ECLS alone. Conclusions From 2016 to 2018 in the United States, use of an Impella and IABP with VA‐ECLS significantly increased. More than half of Impellas and IABPs were placed on the same day as VA‐ECLS, and the use of a second mechanical circulatory support device did not impact in‐hospital mortality. Further studies are needed to decipher the optimal timing and patient selection for this growing practice.

Changing Trends in Mechanical Circulatory Support Use and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Acute Coronary Syndrome Complicated With Cardiogenic Shock: Insights From a Nationwide Registry in Japan

“…The observed in‐hospital mortality in the patients requiring VA‐ECMO was 46.9% to 58.5% with a decreasing trend, which was almost consistent with those in the previous study. 36 The increase in the use of ECPella was about twice as large as that of Impella (12.8% versus 6.6%), which might be partly due to the expectation of left ventricular unloading. Further investigation is required as to whether left ventricular unloading by the concomitant use of an Impella with VA‐ECMO improves the outcome as compared with that by the concomitant use of an IABP with VA‐ECMO.…”

Alterations in Coronary Blood Flow and the Risk of Left Ventricular Distension in Venoarterial Extracorporeal Membrane Oxygenation

“…Another recent single-institution study not included in the meta-analysis reported similar findings. 21 Finally, a recent large “real world” study of the Nationwide Inpatient Sample demonstrated no survival benefits associated with left-sided cardiac unloading 22 ; when subgroup analyses were performed, intra-aortic balloon pumping appeared slightly but not statistically significantly more beneficial than Impella devices. However, most notably in the aforementioned European multi-center study, 10 some evidence does suggest a specific benefit for LV unloading via the Impella family of devices.…”

Cardiogenic Shock: Searching for a Better Lifeboat

“…Both adults and children have a 30‐day survival of 50%, despite markedly different scenarios. Adults without cardiac surgery (in the analysis by Hendrickson et al 12 ) and children with postcardiotomy shock (in the study by Sperotto et al 6 ) had similar poor outcomes. Furthermore, in children, there appears to be a dose‐dependent increase in adverse events with higher pump flow.…”

“…In this issue of the Journal of the American Heart Association ( JAHA ), Hendrickson and colleagues 12 provide a valuable analysis to shed light on the debate over venting in VA‐ECLS. Using the Nationwide Inpatient Sample from 2016 to 2018, the authors identified 12 035 patients undergoing VA‐ECLS (3% of a total of 460 040 patients admitted with CS during this time period).…”