Management and outcome of patients supported with Impella 5.0 for refractory cardiogenic shock.

Philippe Gaudard,Bernard Albat,Geraldine Culas,Jacob Eliet,Philippe Rouvière,Marc Mourad,Norddine Zeroual,Pascal Colson

doi:10.1186/s13054-015-1073-8

Abstract

IntroductionCardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality. Percutaneous left ventricular assist devices may provide a survival benefit for these very sick patients. In this study, we describe our experience with the Impella 5.0 device used in the setting of refractory cardiogenic shock.MethodsIn this observational, retrospective, single-center study we included all the consecutive patients supported with Impella 5.0, between May 2008 and December 2013, for refractory cardiogenic shock. Patients’ baseline and procedural characteristics, hemodynamics and outcome to the first 48 h of support, to ICU discharge and day-28 visit were collected.ResultsA total of 40 patients were included in the study. Median age was 57 years and 87.5 % were male. Cardiogenic shock resulted from acute myocardial infarction in 17 patients (43 %), dilated cardiomyopathy in 12 (30 %) and postcardiotomy cardiac failure in 7 (18 %). In 15 patients Impella 5.0 was added to an ECMO to unload the left ventricle. The median SOFA score for the entire cohort prior to circulatory support was 12 [10–14] and the duration of Impella support was 7 [5–10] days. We observed a significant decrease of the inotrope score (10 [1–17] vs. 1 [0–9]; p = 0.04) and the lactate values (3.8 [1.7–5.9] mmol/L vs. 2.5 [1.5–3.4] mmol/L; p = 0.01) after 6 h of support with Impella 5.0. Furthermore, at Impella removal the patients’ left ventricular ejection fraction improved significantly (p < 0.001) when compared to baseline. Cardiac recovery, bridge to left ventricular assist device or heart transplantation was possible in 28 patients (70 %). Twenty-six patients (65 %) survived at day 28. A multivariate analysis showed a higher risk of mortality for patients with acute myocardial infarction (hazard ratio = 4.1 (1.2–14.2); p = 0.02).ConclusionsImpella 5.0 allowed fast weaning of inotropes and might facilitate myocardial recovery. Despite high severity scores at admission, day-28 mortality rate was better than predicated.

Highlights

Cardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality
Etiologies of Cardiogenic shock (CS) were in order of frequencies: acute ST-elevation myocardial infarction (43 %), end-stage dilated cardiomyopathy (30 %), postcardiotomy (18 %) and others like myocarditis or contusion (10 %)
PVA-ECMO was indicated for hypoxic cardiac arrest occurring during myocardial recovery and caused by acute respiratory distress syndrome in a patient with posttraumatic myocardial contusion

Summary

Introduction

Cardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality. Percutaneous left ventricular assist devices may provide a survival benefit for these very sick patients. Mechanical circulatory support (MCS) is increasingly used, whereas inotropes are associated with adverse events, inadequate circulatory supply or high myocardial oxygen consumption [1]. The Impella 5.0 device (Abiomed Europe GmbH, Aachen, Germany) provides a continuous blood flow up to 5 L/min and is designed to support patients in CS due to isolated LV failure for 10 days. Recent data have suggested that percutaneous left ventricular assist devices (LVADs) may provide a survival benefit for patients with refractory CS after myocardial infarction [10] or cardiotomy [11,12,13]. Optimal LV unloading, which procures optimal myocardial oxygen supply/demand ratio, is better achieved with Impella, with or without associated PVA-ECMO [14, 15]. The use of Impella 2.5 devices (but not of Impella 5.0) for LV unloading in case of severe LV distension for patients on PVA-ECMO was previously described in case reports [16,17,18,19] and seems to be a promising therapeutic option

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