Biventricular unloading with Impella on top of veno-arterial membrane oxygenation improves short- and long-term survival in refractory post-cardiac arrest cardiogenic shock

Abstract

Abstract Background Patients with refractory post-cardiac arrest (CA) cardiogenic shock (RCS) may present with LV-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical circulatory support (MCS) with Impella or veno-arterial membrane oxygenation (vaECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge these patients in definite therapies. However, the selection of the appropriate MCS device should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Especially vaECMO patients may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery. Nowadays there is no data concerning the role of biventricular unloading with an Impella on top of a vaECMO in the homogenous group of post-CA RCS. Purpose To report our experience from the combined use of Impella (2.5 and CP) on top of a vaECMO in the homogenous group of patients with post-CA RCS. Methods Single center study of consecutive patients with biventricular unloading with Impella after initial vaECMO support over a 6-year period suffering from post-CA RCS. Propensity scoring matching analysis was used to account for the differences in baseline data between the two groups. Results A total of 91 patients underwent vaECMO support for RCS, whereas in another 32 patients initial vaECMO support was escalated with an Impella (75% CP) (BiVent group). Mean age was 60.88 ± 9.8 and 98 (80%) patients were male. Survival rates were similar in both groups (hospital survival: BiVent 40.6% and vaECMO 33%, p=0.52; 12-month survival BiVent 37.5% and vaECMO 31.9%, p=0.67). After adjustment for baseline difference with propensity scoring matching analysis, survival rates were significantly better in the BiVent group (hospital and 12-month survival: BiVent 50% and vaECMO 17%, p=0.03 (Figure 1). Vasopressor doses and lactate levels decreased significantly more firmly in the BiVent group within 72 h on biventricular support compared to vaECMO (p<0.05). Moreover, the patients in the BiVent group demonstrated a greater functional recovery of the LV at 96 hours after admission compared to vaECMO patients (Figure 2). Conclusions Impella on top of vaECMO improves short- and long-term survival in patients with post-cardiac arrest refractory cardiogenic shock leading to a better restoration of the left ventricle and end organ function.