Unloading using Impella CP during profound cardiogenic shock caused by left ventricular failure in a large animal model: impact on the right ventricle

Abstract

Background and aim: This study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine. Methods: Cardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. Conductance catheters were placed in both ventricles and pressure-volume loops were recorded simultaneously. Results: Cardiogenic shock due to LV failure also impaired RV performance, which was partially restored during haemodynamic support with Impella CP, as demonstrated by changes in the ventriculo-arterial coupling (Ea/Ees ratio) (baseline (median [Q1;Q3]) 1.2 [1.1;1.6]), cardiogenic shock (3.0 [2.4;4.5]), Impella CP (2.1 [1.3; 2.7]) (p Baseline vs CS < 0.0001, p CS vs Impella = 0.001)). Impella CP support also improved RV stroke work (SW) (cardiogenic shock 333 [263;530] vs Impella CP (830 [717;1121]) (p < 0.001). Moderate norepinephrine infusion concomitant with Impella CP further improved RV SW (Impella CP (818 [751;1065]) vs Impella CP+moderate norepinephrine (1231 [1142;1335]) (p = 0.01)) but at the expense of an increase in LV SW (Impella CP (858 [555;1392]) vs Impella CP+moderate norepinephrine (2101 [1024;2613]) (p = 0.04)). Conclusions: The Impella CP provided efficient LV unloading, improved RV function, and end-organ perfusion. Moderate doses of norepinephrine during Impella support further improved RV function, but at the expense of an increase in SW of the failing LV.

Fulminant myocarditis spreading from the right ventricle treated with extracorporeal membrane oxygenation and impella

“…Moreover, it decreases wall stress, cardiac innate immunity, adhesion molecule expression and immune cell infiltration 11 29 30. In this case with right ventricular failure, Impella may have reduced the load on the right ventricle and led to improvement 31 32…”

A Meta-Analysis Comparing Venoarterial (VA) Extracorporeal Membrane Oxygenation (ECMO) to Impella for Acute Right Ventricle Failure

“…Worth mentioning is that we found two animal studies (Josiassen et al 2020 andYastrebov et al 2020) [8,10], which helped in providing introductory information to our research, however, their weight in the analysis was not estimated.…”

“…There has been a considerable rise in the usage of subcutaneous mechanical support (SMS) in the past 10 years. Following recent findings on the dubious usefulness of intra-aortic balloon pumps (IABPs), especially in sensitive post-infarction shock, it is expected that emerging devices that provide better circulatory support would have more therapeutic benefits [ 8 - 9 ]. The TandemHeart or ECMO and the Impella transaortic intraventricular pump [ 8 ] are among the most commonly utilized extracorporeal devices.…”

“…Following recent findings on the dubious usefulness of intra-aortic balloon pumps (IABPs), especially in sensitive post-infarction shock, it is expected that emerging devices that provide better circulatory support would have more therapeutic benefits [ 8 - 9 ]. The TandemHeart or ECMO and the Impella transaortic intraventricular pump [ 8 ] are among the most commonly utilized extracorporeal devices. The Impella device has been authorized in Europe since 2005, according to the European Commission, for a range of manifestations, with the inclusion of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock.…”

“…Uncertainty over the best use of particular devices in different clinical situations, as well as disparities in reimbursement conditions throughout the area, may all play a role [ 11 ]. The Impella Working Group, which has a combined exposure of over 1000 European Impella implantations, seeks to provide a current overview of the state of the art, allowing for more in-depth knowledge of the Impella technology's foundations and fundamental application [ 8 ]. The Impella system consists of a 9 F catheter and a small axial pump that work together.…”