Use of Impella in Patients Listed for Heart Transplantation

Abstract

The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.

Recent Advances and Outcomes in Heart and Lung Transplantation

“…Recently, more research is being done on assist devices that can be implanted percutaneously. After the UNOS heart allocation policy change, the use of percutaneous devices like Impella jumped from 1% in 2015 to 4% in 2019 among transplant patients [85]. Impella is a catheter-based ventricular assist device for unloading the left ventricle and consequently increasing cardiac output.…”

A New Dawn for Transvalvular Pumps for Ventricular Unloading as a Bridge to Heart Transplantation

“…Based on the International Society for Heart and Lung Transplantation registry, bridge to transplantation (BTT) with a percutaneous VAD (n = 75) was independently associated with greater risk of posttransplant mortality (hazard ratio, 1.83; 95% CI, 1.09–3.08; p < 0.02) with a survival of 1 year at 79.9%. 11 The current study does not allow for detailed longitudinal hemodynamic and metabolic profiling, inotrope/vasoactive index, and specific and sequential device utilization compared with contemporary cohorts, which is a limitation of the registry. The small cohort size (limited to only 1 year postallocation policy change) with a limited follow-up time in this submission does not extend our ability to understand the long-term outcomes post HT.…”

“…More importantly, it has had a significant influence on the field of tMCS and bridge to transplant strategies. The comparative use and outcomes of Impella platforms as bridge to HT before and after policy change are described by Pahwa et al 11 Since October 2018, there was incremental changes in Impella platform utilization, with the most common device being Impella 5.0. There were 378 patients that received Impella support before HT, of which 179 were placed on support after UNOS policy change.…”

“…9 In this issue of the Journal, Impella platforms are explored by addressing both the clinical aspects in an ICU setting as an overview (and single-center experience) as well as a contemporary registry analysis from the United Network of Organ Sharing (UNOS), describing characteristics and outcomes associated with its use before HT. 10,11…”

“…9 In this issue of the Journal, Impella platforms are explored by addressing both the clinical aspects in an ICU setting as an overview (and single-center experience) as well as a contemporary registry analysis from the United Network of Organ Sharing (UNOS), describing characteristics and outcomes associated with its use before HT. 10,11 Papolos et al 10 describe the critical care-oriented perspective of Impella-based devices with an emphasis on management, repositioning, and monitoring, describing a single-center experience of 91 patients supported with various Impella platforms. The authors describe the Impella system in terms of hemodynamic effects and general principles, with an emphasis on structural design and capacities across the five different available catheters as well as technicalities placement, repositioning, and monitoring of aortic and left ventricular pressures by an optical pressure sensor.…”