Impella 5.0 Reduces Vasoactive Agents In Cardiogenic Shock

Abstract

Introduction Mortality remains high in cardiogenic shock (CS) despite recent emphasis on multidisciplinary approach with early identification and initiation of mechanical circulatory support (MCS). The microaxial ventricular assist device (VAD), Impella 5.0® (Abiomed, Danvers, MA), is an acute MCS device effective in unloading the left ventricle and providing circulatory support to facilitate cardiac recovery or bridge to durable therapies. Escalation in pharmacologic support of CS with vasopressors and inotropes have been associated with increased mortality. We evaluated the impact of the early use of Impella 5.0 in CS with respect to vasoactive agent requirements and clinical outcomes. Methods Retrospective analysis was performed on 14 consecutive patients in CS admitted to the University of Pittsburgh Medical Center between Jan. 2019 - March 2020 implanted with Impella 5.0. Hemodynamic data was collected pre-implantation and up to 72 hours post-implantation. The Vasoactive-Inotropic Score (VIS) and an adjusted Catecholamine Equivalent (CE) score were used to quantify vasopressor and inotrope use for cardiovascular support. Results Most patients were male (86%) with a mean age of 55 ± 11.0 years. Etiologies of CS were acute myocardial infarction (29%) and decompensated heart failure (71%). Use of Impella 5.0 was associated with a reduction in RAP, mPAP, and PCWP that was apparent after 4 hours and continued up to 72 hours post-implantation (RAP: 18 [12, 23], 9 [7, 14], 12 [7, 15]; mPAP: 40 [37, 48], 29 [26, 34], 30 [25, 31]; PCWP: 32 [28, 37], 23 [15, 26], 21 [18, 23] at pre-implantation, 4, and 72 hours after implantation respectively). An immediate and sustained increase in CI, CPO, and PAPi was also demonstrated up to 72 hours (CI: 1.79 [1.38, 2.09], 2.31 [1.93, 2.83], 2.5 [2.04, 2.75]; CPO: 0.54 [0.44, 0.81], 0.8 [0.66, 1.08], 0.80 [0.69, 0.92]; PAPi: 1.26 [0.90, 1.73], 2.145 [1.32, 2.81], 2.0 [1.23, 2.57] at pre-implantation, 4, and 72 hours after implantation respectively). The mean number of vasopressor and inotropes at 72 hours were reduced from 1.92 to 1, along with a sustained reduction in the VIS and CE scores up to 72 hours (Figure 1). The burden of ventricular arrhythmias also decreased post-implantation. Survival occurred in 11 patients (78.6%), with all being discharged from the hospital. Two patients received heart transplants, six received durable LVADs, and three recovered. Conclusions Early initiation of acute MCS with Impella 5.0 in CS is associated with an improvement in hemodynamic parameters and a reduction in vasoactive agents as demonstrated by the VIS and CE score, with favorable clinical outcomes.