Invited Commentary

Abstract

Lemaire and colleagues [1Lemaire A. Anderson M.B. Lee L.Y. et al.The Impella device for acute mechanical circulatory support in patients in cardiogenic shock.Ann Thorac Surg. 2014; 97: 133-138Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar] report their experience with the Impella (Abiomed Inc, Danvers, MA) microaxial-flow left ventricular assist device (LVAD) in the setting of cardiogenic shock. The authors reported successful removal of the device in 34 of 47 patients (72%), with only 4 patients requiring transition to long-term LVAD support. The 30-day, 90-day, and 1-year survival was 72%, 66%, and 64%, respectively. The historical context of this report is noteworthy. Minimally invasive mechanical circulatory assist began in the 1960s with the intraaortic balloon pump (IABP) [2Kantrowitz A. Tjonneland S. Freed P.S. et al.Initial clinical experience with intra-aorta balloon pumping in cardiogenic shock.JAMA. 1968; 203: 113-118Crossref PubMed Scopus (585) Google Scholar] and in the 1970s with the Hemopump (Medtronic Inc, Minneapolis, MN). In 1989 Frazier and colleagues [3Frazier O.H. Nakatani T. Duncan J.M. et al.Clinical experience with the Hemopump.ASAIO Trans. 1989; 35: 604-606Crossref PubMed Google Scholar] reported the use of the Hemopump in 12 patients: 6 of the 12 survived 30 days. Although the Hemopump is no longer used, the template of a minimally invasive LVAD was forged. Preceding this study, other multicenter trials validated Impella use in high-risk percutaneous coronary intervention (ie, A Prospective, Multi-center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump [IABP] in Patients Undergoing Non Emergent High Risk PCI [PROTECT II]) and in postcardiotomy shock (ie, IMPELLA® RECOVER® LP/LD 5.0 Support System: A Clinical Safety and Feasibility Study [RECOVER I] [4O'Neill W.W. Kleiman N.S. Moses J. et al.A prospective randomized clinical trial of hemodynamic support of Impella 2.5 versus intra aortic balloon pump in patients undergoing high risk percutaneous coronary intervention: the PROTECT II Study.Circulation. 2012; 126: 1717-1727Crossref PubMed Scopus (531) Google Scholar, 5Griffith B.P. Anderson M.B. Samuels L.E. et al.The RECOVER I: a multicenter prospective study of Impella 5.0/LD for postcardiotomy circulatory support.J Thorac Cardiovasc Surg. 2013; 145: 548-554Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar]. A continental registry (ie, EUROSHOCK Registry) tracks outcomes of acute myocardial infarction patients supported with the Impella 2.5; a recent report of 120 patients demonstrated a 64.2% 30-day mortality rate, with survival at 317 ± 526 days reported at only 28.3% [6Lauten A. Engström A.E. Jung C. Empen K. et al.Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry.Circ Heart Fail. 2013; 6: 23-30Crossref PubMed Scopus (237) Google Scholar]. Clearly, there is room for improvement. In summary, the disease states that lead to acute cardiogenic shock have not changed in the past 50 years, but the technology to combat it has. The use of multiple and escalating doses of high-dose inotropes to treat low cardiac output is associated with unacceptable mortality and should be abandoned and replaced by mechanical circulatory support [7Samuels L.E. Kaufman M.S. Morris R.J. Pharmacologic criteria for ventricular assist device insertion: experience with the Abiomed BVS 5000 system.J Card Surg. 1999; 14: 288-293Crossref PubMed Scopus (119) Google Scholar]. The experience reported by Lemaire and colleagues [1Lemaire A. Anderson M.B. Lee L.Y. et al.The Impella device for acute mechanical circulatory support in patients in cardiogenic shock.Ann Thorac Surg. 2014; 97: 133-138Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar] is noteworthy and commendable. Impella technology and minimally invasive products like it are transforming the landscape of surgical and interventional treatment of this deadly condition. The Impella Device for Acute Mechanical Circulatory Support in Patients in Cardiogenic ShockThe Annals of Thoracic SurgeryVol. 97Issue 1PreviewAcute cardiogenic shock is associated with high mortality rates. Mechanical circulatory devices have been increasingly used in this setting for hemodynamic support. The Impella device (Abiomed Inc, Danvers, MA) is a microaxial left ventricular assist device that can be inserted using a less invasive technique. This study was conducted to determine the outcome of patients who have undergone placement of the Impella device for acute cardiogenic shock in our institution. Full-Text PDF