Abstract
Background and aimThis study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine.MethodsCardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. Conductance catheters were placed in both ventricles and pressure-volume loops were recorded simultaneously.ResultsCardiogenic shock due to LV failure also impaired RV performance, which was partially restored during haemodynamic support with Impella CP, as demonstrated by changes in the ventriculo-arterial coupling (Ea/Ees ratio) (baseline (median [Q1;Q3]) 1.2 [1.1;1.6]), cardiogenic shock (3.0 [2.4;4.5]), Impella CP (2.1 [1.3;2.7]) (pBaseline vs CS < 0.0001, pCS vs Impella = 0.001)). Impella CP support also improved RV stroke work (SW) (cardiogenic shock 333 [263;530] vs Impella CP (830 [717;1121]) (p < 0.001). Moderate norepinephrine infusion concomitant with Impella CP further improved RV SW (Impella CP (818 [751;1065]) vs Impella CP+moderate norepinephrine (1231 [1142;1335]) (p = 0.01)) but at the expense of an increase in LV SW (Impella CP (858 [555;1392]) vs Impella CP+moderate norepinephrine (2101 [1024;2613]) (p = 0.04)).ConclusionsThe Impella CP provided efficient LV unloading, improved RV function, and end-organ perfusion. Moderate doses of norepinephrine during Impella support further improved RV function, but at the expense of an increase in SW of the failing LV.
Highlights
Cardiogenic shock is the most severe manifestation of ventricular failure, with 30-day mortality remaining as high as 50% [1,2,3]
This study aimed to assess right ventricular (RV) function in terms of stroke work (SW), pressure-volume area (PVA), and the interventricular end-diastolic volume (EDV) relationship during experimentally induced profound cardiogenic shock in pigs caused by microsphere injections in the left main coronary artery, leading to left ventricular (LV) failure
Effect of cardiogenic shock induction Profound cardiogenic shock was achieved in all the pigs following repetitive injections of microspheres in the left main coronary artery, causing a significant reduction in Cardiac output (CO), SvO2 and mean arterial pressure (MAP) (Table 1)
Summary
Cardiogenic shock is the most severe manifestation of ventricular failure, with 30-day mortality remaining as high as 50% [1,2,3]. Observational studies assessing the effect of the Impella devices in cardiogenic shock show mixed results and to date, no adequately powered randomized controlled trial has been conducted. Given the complex and emergent nature of cardiogenic shock and subsequent difficulty in conducting controlled trials, other studies assessing different aspects of physiologic changes during treatment with the Impella CP is important to enable optimisation of the devices used. Previous animal studies have shown that the Impella CP is efficient in terms of acute left ventricular (LV) unloading and flow restoration, organ support is not as efficient as treatment with extracorporeal life support [5]. This study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine
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