Increased Incidence of De Novo Aortic Incompetence in Patients Supported with Impella Prior to LVAD Implantation

Abstract

Purpose Impella (Abiomed Inc, Danvers, MA) is a temporary mechanical support device being more frequently used in INTERMACS 1 patients bridged to LVAD implantation. The device is percutaneously inserted across the aortic valve, and although case reports describe the development of aortic incompetence (AI) after its use, there is no data on the incidence of AI in patients with Impella support as a bridge to LVAD implantation. Methods We reviewed all patients undergoing primary LVAD implantation at a large academic center from January 2015 onwards, and identified those classified as INTERMACS 1. We then divided them by method of pre-implantation support, comparing those supported with Impella as temporary mechanical support to those supported by either VA ECMO or IABP. We reviewed transthoracic echocardiography preoperatively, as well as at 1 week, 1, 3, 6, 9 and 12 months post-LVAD implantation. Patients with concomitant Aortic Valve Replacement were excluded. Results A total of 155 patients were reviewed, of which 45 patients were identified as INTERMACS 1. A total of 179 echoes were analysed. Twelve patients were supported with Impella prior to LVAD implant - of which six patients were supported with Impella alone (5 with Impella CP, 1 with Impella 5) and six with Impella in conjunction with VA ECMO (3 with Impella 2.5, 2 with Impella CP and 1 with Impella 5). One of the patients supported with Impella died within three days of LVAD implant and was excluded from analysis. Post LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared to 43% of those without Impella (13 of 30) [p = 0.038]. There was no difference in severity or incidence of AI based on type of Impella device or type of LVAD used. Conclusion In our cohort, patients supported with Impella as a bridge to durable LVAD have higher risk of developing AI. Further studies are needed to identify risk factors and develop strategies to mitigate this risk as the use of Impella becomes more widespread. Impella (Abiomed Inc, Danvers, MA) is a temporary mechanical support device being more frequently used in INTERMACS 1 patients bridged to LVAD implantation. The device is percutaneously inserted across the aortic valve, and although case reports describe the development of aortic incompetence (AI) after its use, there is no data on the incidence of AI in patients with Impella support as a bridge to LVAD implantation. We reviewed all patients undergoing primary LVAD implantation at a large academic center from January 2015 onwards, and identified those classified as INTERMACS 1. We then divided them by method of pre-implantation support, comparing those supported with Impella as temporary mechanical support to those supported by either VA ECMO or IABP. We reviewed transthoracic echocardiography preoperatively, as well as at 1 week, 1, 3, 6, 9 and 12 months post-LVAD implantation. Patients with concomitant Aortic Valve Replacement were excluded. A total of 155 patients were reviewed, of which 45 patients were identified as INTERMACS 1. A total of 179 echoes were analysed. Twelve patients were supported with Impella prior to LVAD implant - of which six patients were supported with Impella alone (5 with Impella CP, 1 with Impella 5) and six with Impella in conjunction with VA ECMO (3 with Impella 2.5, 2 with Impella CP and 1 with Impella 5). One of the patients supported with Impella died within three days of LVAD implant and was excluded from analysis. Post LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared to 43% of those without Impella (13 of 30) [p = 0.038]. There was no difference in severity or incidence of AI based on type of Impella device or type of LVAD used. In our cohort, patients supported with Impella as a bridge to durable LVAD have higher risk of developing AI. Further studies are needed to identify risk factors and develop strategies to mitigate this risk as the use of Impella becomes more widespread.