IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock.

Guillaume Schurtz,Emmanuel Robin,Gilles Lemesle,Clément Delmas,Sina Porouchani,André Vincentelli,Basile Verdier,Alessandro Cosenza,Laurent Bonello,Vincent Balmette,Nicolas Lamblin,Ouriel Saura,Flavien Vincent,Natacha Rousse,Mouhamed Djahoum Moussa,Nadia Aïssaoui ,Françis Juthier ,Cédric Delhaye,Éric Van Belle ,Étienne Puymirat

doi:10.3390/jcm10040759

Abstract

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

Highlights

Despite improvements in heart failure (HF) pharmacological therapies and widespread use of timely reperfusion in acute myocardial infarction (MI), cardiogenic shock (CS) is still associated with a dismal prognosis and major resource utilization [1]
In patients eligible to either veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or IMPELLA® for left ventricle (LV) dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation
The present analysis aimed to compare patients who were first implanted with the IMPELLA® device (n = 31) to those first implanted with VA-ECMO (n = 97) as Mechanical circulatory support (MCS) device (Figure 1)

Summary

Introduction

Despite improvements in heart failure (HF) pharmacological therapies and widespread use of timely reperfusion in acute myocardial infarction (MI), cardiogenic shock (CS) is still associated with a dismal prognosis and major resource utilization [1]. Standard of care and current guidelines support the use of vasoactive agents (inotropes and/or vasopressors) to maintain adequate cardiac output [2]. This strategy exposes the patients to increased afterload, increased myocardial oxygen demand and higher risk of arrhythmias that could lead at the end to impaired perfusion, further clinical deterioration and death [3]. A careful multimodal evaluation by a dedicated Shock Team (critical care physicians, cardiac intensivists, interventional cardiologists, cardio-thoracic surgeons, advanced heart failure specialists, and anesthesiologist) is recommended to ensure correct CS phenotyping, allowing tailored and early interventions with adequate MCS selection

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