Impella Device Research Articles

Abstract 4120140: Catastrophic Bioprosthetic Aortic Valve Thrombosis: An Unappreciated Complication of Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock

Description of Case: A 56-year-old male with a history of cardiac sarcoidosis with biventricular systolic heart failure (HF) and a bioprosthetic aortic valve presented with acute decompensated HF. Progressive cardiogenic shock and hemodynamic instability ensued, requiring urgent bedside placement of an intra-aortic balloon pump (IABP) which provided only marginal hemodynamic support. After extensive multidisciplinary discussion, emergent cannulation for veno-arterial ECMO (VA-ECMO) was performed at the bedside as a bridge-to-decision for advanced HF therapies. The IABP was left in place for LV venting. Within 72 hours, extensive bilateral pulmonary opacities had developed. It was later realized that true LV ejection (as evidenced by aortic pulsatility on the arterial line) was not present and had been masked by pseudo-pulsatility provided by IABP inflations and deflations. Compared to an echocardiogram done 7 days prior to VA-ECMO cannulation, the bioprosthetic leaflets were no longer opening, thrombosis of the AV had occurred, and thrombus formation along the ECMO venous drainage cannula was noted. Failure to achieve LV venting culminated in complete thrombosis of the entire LV and LA and the patient ultimately expired. Discussion: Bioprosthetic valve thrombosis is a lesser-known complication of VA-ECMO support, with most reports involving bioprosthetic valves in the mitral position. Indeed, bioprosthetic valve thrombosis occurs at a higher rate than native valve thrombosis during VA-ECMO support. However, bioprosthetic AV thrombosis is an extremely rare complication of VA-ECMO support and arguably results in a more catastrophic scenario as most traditional approaches to LV unloading are contraindicated. The optimal LV unloading strategy for these patients (IABP, Impella, surgical apical unloading, etc) is unknown. Data from large retrospective analyses have demonstrated extremely poor outcomes when prosthetic valve thrombosis occurs, and it is thus critical to prevent this complication from developing. In contrast to IABP counter-pulsation, the benefit of upfront transvalvular LV venting with an Impella device safeguards the presence of a direct LV vent in the event of bioprosthetic AV thrombosis and eliminates the false reassurance of IABP pseudo-pulsatility. Further studies are needed to better elucidate the optimal LV unloading strategy in patients with bioprosthetic valves, particularly in the aortic position.

Outcomes of Older Patients With Cardiogenic Shock Using the Impella Device - Insights From the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD).

Aging has progressed in several regions of the world with more older patients experiencing acute cardiovascular disease. Impella is a percutaneous potent circulatory support device associated with substantial cost and potential device-related complications. We analyzed the Japanese nationwide registry, encompassing consecutive patients with cardiogenic shock using Impella. Among 5,718 patients treated between 2020 and 2022, we compared older patients (≥75 years) with younger patients. The primary outcome was the Kaplan-Meier estimated 30-day mortality, and the secondary outcome was Impella-related complications. The median age of the 5,718 patients was 69 (58-77) years, and 1,807 (31.6%) were older, with smaller body mass index, frequent acute coronary syndrome, and infrequent myocarditis. Comorbidities were frequently observed in older patients with a higher ejection fraction and less frequency of extracorporeal membrane oxygenation. Older patients had a higher 30-day mortality than younger patients (38.9% vs. 32.5%; P<0.0001). The 30-day mortality was statistically equivalent among older subsets (75-79 vs. 80-84 vs. ≥85 years). Device-related complications similarly occurred similarly among the older subsets, except for a modest increase in cardiac tamponade and limb ischemia. Older age, body mass index, myocarditis, prior arrhythmia, shock severity, renal and hepatic impairment, and limb ischemia were associated with 30-day mortality. The selected older patients using Impella exhibited modestly higher 30-day mortality with similar safety profiles. A longer follow up and optimal patient selection are important.

Right ventricular free wall longitudinal strain as a predictor of myocardial recovery in patients with advanced cardiogenic shock supported with the Impella device

Abstract Background Right ventricular (RV) dysfunction is a known independent factor influencing the outcome of patients in cardiogenic shock (CS). The aim of this monocentric retrospective study was to investigate the impact of left ventricular (LV) unloading on the right heart function and its predictive role regarding weaning following Impella device implantation in patients with profound CS due to LV failure. Methods We performed a retrospective analysis of 41 patients admitted to intensive care unit over a period of 3 years with CS due to LV dysfunction requiring support with Impella. Clinical and echocardiographic data were collected and correlated with weaning success. Finally, a multivariate analysis to identify independent predictors of weaning success was performed. Results After Impella implantation, the following was observed: right ventricular fractional area change (RVFAC) increased from a mean value of 28% to 38% (p=0.01), the tricuspid annular systolic velocity (TASV) increased from 9 cm/s to 10 cm/s (p=0.01), the velocity time integral right ventricular outflow tract (VTI RVOT) increased from 10 to 13 cm3/stroke (p=0.01), the right ventricular free wall longitudinal strain (RVFWLS) increased from -12% to -21% (p&amp;lt; 0.001). However, following LV unloading, a decrease in both RVFAC from 38% to 30% (p 0.01) and in VTI RVOT from 13 to 11 cm3/stroke (p&amp;lt;0.01) was observed. Moreover, there was a significant decrease in RVFWLS from -21% to -14% (p &amp;lt; 0.001). Notably, the percentage of change in RVFWLS between maximum and minimum (Δ%RVFWLSPmax-Pmin) support with Impella during the weaning process was significantly lower in weanable patients (34.5% in weaned vs 86% in non-weaned; p=0.038). Investigating the predicting ability of these parameters, Δ%RVFWLSPmax-Pmin emerged showing an AUC of 0.826 (0.690-0.962) in identifying non-weaned patients with a cut-off value of 38%. According to the multivariate analysis, Δ%RVFWLSPmax-Pmin in non-weaned patients remained the only significant parameter even considering possible confounders. Conclusions LV unloading with Impella in advanced CS patients improved RV function echocardiographic parameters. RVFWLS increased significantly after Impella implantation and its percentage of change between maximum and minimum support was significantly lower in weanable compared to non-weanable patients. Our findings suggest that RVFWLS could be used as a predictor of myocardial recovery allowing to identify weanable patients with adequate accuracy.

Prognostic Survey of ECPELLA in Japanese Patients With Acute Myocardial Infarction and Cardiogenic Shock - Findings From the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD).

The short-term mortality associated with veno-arterial extracorporeal membrane oxygenation combined with the Impella device (termed ECPELLA) for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains unclear. The Japanese Registry for Percutaneous Ventricular Assist Devices (J-PVAD) includes data on all patients treated with an Impella in Japan. We extracted data for 922 AMI-CS patients who underwent ECPELLA support and conducted an exploratory analysis focusing on 30-day mortality. The median age of patients was 69 years, and 83.8% were male. The overall 30-day mortality was 46.1%. Factors associated with mortality included age >80 years, in-hospital cardiac arrest, systolic blood pressure <90 mmHg, serum creatinine >1.5 mg/dL, and serum lactate >4.0 mmol/L. In patients aged >80 years with any of these factors, mortality was significantly higher than in those without, ranging from 57.5% to 64.9%. The J-PVAD score assigns 1 point per predictor, with a C-statistic of 0.620 (95% confidence interval 0.586-0.654). The 30-day mortality was 20.0% for a J-PVAD score of 0, increasing to 70.0% for a score of 5. The J-PVAD data indicate high short-term mortality in AMI-CS patients treated with ECPELLA, particularly among older patients. Further studies are needed to validate this risk stratification in this patient subset.

The use of perioperative Impella 5.5 support in high-risk cardiac surgery: a retrospective cohort study.

Although the Impella device has an established role in high-risk percutaneous intervention and cardiogenic shock, its role in open cardiac surgery remains unclear. We undertook this study to better understand the role of Impella support in cardiac surgical intervention. This is a retrospective cohort study of consecutive patients who underwent cardiac surgery with surgically placed Impella 5.5 device support from October 2020 through June 2023. Patient charts were identified and systematically reviewed for relevant information. The primary outcome for this study was patient survival to discharge. Secondary outcomes included intraoperative survival, 30-day survival and 1-year survival. From 2020-2023, ten patients underwent open cardiac surgery with Impella 5.5 support. Five patients were male and the median age was 56.5 years [interquartile range (IQR), 52-63.8 years]. Three patients (30%) presented for isolated revascularization, 3 patients (30%) presented for single valve surgical intervention, 3 patients (30%) presented for revascularization and valve intervention, and 1 patient (10%) presented for multivalve intervention. The median ejection fraction (EF) of patients was 25% (IQR, 21.25-32.5%), the median Society of Thoracic Surgeons risk score was 4.32% (IQR, 1.73-11.06%). Of the patients, 40% underwent axillary cannulation while 60% had central cannulation. Intraoperative survival was 100%, survival to discharge was 90% and 30-day survival was 80%. Our study suggests the use of surgical Impella in high-risk cardiac surgical patients is associated with acceptable survival regardless of site or timing of cannulation. However, Impella usage is associated with significant morbidity. Further investigation is warranted to better understand which patients benefit perioperative Impella support.

Mechanical Circulatory Support with Impella: Principles, Evidence, and Daily Practice.

The Impella (Abiomed, Danvers, MA, USA) microaxial pump is a percutaneous mechanical circulatory support (MCS) that has been shown to increase coronary perfusion, reduce myocardial oxygen demand, and improve peripheral organ perfusion. Therefore, indications for the Impella device include emergency use for cardiogenic shock (CS) and pre-emptive implantation during high-risk percutaneous coronary intervention (HR-PCI). However, despite their exponential use in cardiovascular practice over the past decade, there is limited randomized evidence to support the benefits of this therapy and growing concern regarding complication rates. In this review, we summarize the principles, evidence, and practical considerations of the most widely used Impella CP percutaneous left ventricular support in both CS and HR-PCI settings, moving from the historical background to current issues and future expectations for this device.

Left ventricular unloading via percutaneous assist device during extracorporeal membrane oxygenation in acute myocardial infarction and cardiac arrest.

A feared complication of an acute myocardial infarction (AMI) is cardiac arrest (CA). Even if return of spontaneous circulation is achieved, cardiogenic shock (CS) is common. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) supports patients with CS and is often used in conjunction with an Impella device (2.5 and CP) to off-load the left ventricle, although limited evidence supports this approach. The goal of this study was to determine whether a mortality difference was observed in VA-ECMO alone versus VA-ECMO with Impella (ECPELLA) in patients with CS from AMI and CA. A retrospective chart review of 50 patients with AMI-CS and CA and were supported with VA-ECMO (n = 34) or ECPELLA (n = 16) was performed. The primary outcome was all-cause mortality at 6-months from VA-ECMO or Impella implantation. Secondary outcomes included in-hospital mortality and complication rates between both cohorts and intensive care unit data. Baseline characteristics were similar, except patients with ST-elevation myocardial infarction were more likely to be in the VA-ECMO group (p = 0.044). The ECPELLA cohort had significantly worse survival after VA-ECMO (SAVE) score (p = 0.032). Six-month all-cause mortality was not significantly different between the cohorts, even when adjusting for SAVE score. Secondary outcomes were notable for an increased rate of minor complications without an increased rate of major complications in the ECPELLA group. Randomized trials are needed to determine if a mortality difference exists between VA-ECMO and ECPELLA platforms in patients with AMI complicated by CA and CS.

Impella support for refractory cardiogenic shock accompanied by diabetic ketoacidosis: a case report.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are strongly recommended in patients with heart failure, regardless of the presence of diabetes mellitus. A 74year-old woman with a reduced left ventricular ejection fraction and diabetes mellitus (the types were unknown), receiving insulin and SGLT2 inhibitor, was hospitalized for altered consciousness with systemic hypotension. Upon admission, she was diagnosed with cardiogenic shock due to diabetic ketoacidosis. Intensive fluid resuscitation under Impella CP support successively improved her metabolic acidosis, preventing worsening pulmonary congestion by mechanically unloading the heart. After hemodynamic stabilization, she was diagnosed with type 1 diabetes mellitus for the first time. She was discharged on day 54 and was followed for 6months without any recurrences. We must remain vigilant regarding the risk of diabetic ketoacidosis in patients using SGLT2 inhibitors, particularly those on insulin therapy or with diabetes mellitus of unknown types. Impella device shows promise as a circulatory support system in alleviating the left ventricle's workload and averting exacerbated pulmonary congestion, especially in cases where patients necessitate aggressive fluid replacement therapy, such as in the treatment of diabetic ketoacidosis concurrent with compromised cardiac function.

First experiences with protected VT ablation using surgical Impella 5.5

Abstract Introduction Ablation of ventricular arrhythmias (VA) is still challenging due to the complex substrate of the underlying heart disease. Depending on specific risk factors acute hemodynamic decompensation during or after VT ablation procedures may occur and hemodynamic support may be required. Protected VA ablation with different devices has been evaluated but associated complications like bleeding, vascular closure or weaning from the device have been restrictive. We present data on a dedicated approach to patients with anticipated hemodynamic deterioration using preventive surgical Impella support. Method 5 patients (2 female) underwent protected VT ablation under our standardized protocol. Indication for Impella support was severely impaired left ventricular function and multiple medical therapy refractory ventricular arrhythmias. 4 patients had conventional VT ablation before. Mean age was 66,8 years, mean CHADSVASC 4,4, 1 patient with non-ischemic cardiomyopathy (CMP), 1 with hypertrophic non-obstructive CMP, 3 patients with ischemic CMP. Mean EF was 20%, mean mixed venous saturation was 36 %, mean PAINESD score 27. In all patients a 5.5. Impella was implanted surgically 1 day before planned VT ablation via the right subclavian artery. VT ablation procedure started with substrate mapping, VT induction and activation mapping of the inducible VT to identify the critical VT isthmus. Ablation was directed to dissection of the critical isthmus of inducible VAs and elimination of all late potentials within low voltage areas. The Impella device was explanted after weaning off the hemodynamic support. Results Implantation of Impella 5.5 was successfully performed in all patients in general anesthesia without any complication via surgical approach. Specifically, no access site vascular complications were noted. In 4 patients the VT ablation procedure was performed in analgosedation, 1 patient in GA as this patient was intubated due to recurrent VA requiring defibrillation. Mean procedure time was 125 min, radiation time 1,3 min, inducible VTs 1,3 , median 2 morphologies. In all patients all inducible VTs could be eliminated, in 1 patient polymorphic VA was still inducible at the end of the procedure. Impella was explanted after mean 5,2 days (3-11 days). No complications occurred. All patients were discharged alive on heart failure medication and in 2 patients with amiodaron. At a mean follow up of 3.5 months, all patients are alive without VA recurrence and heart failure decompensation. Conclusion Surgical Impella implantation for protected VT ablation in severe heart failure patients is feasible and allows for effective VT mapping and ablation. Access site safety and protection for heart failure decompensation in addition to the possibility of individually mobilisation and weaning after the procedure make this protocol an attractive option. Prospective evaluation of standardized indication is needed.

The intelligent Impella: Future perspectives of artificial intelligence in the setting of Impella support.

Artificial intelligence (AI) has emerged as a potential useful tool to support clinical treatment of heart failure, including the setting of mechanical circulatory support (MCS). Modern Impella pumps are equipped with advanced technology (SmartAssist), enabling real-time acquisition and display of data related to both pump performance and the patient's haemodynamic status. These data emerge as an 'ideal' source for data-driven AI applications to predict the clinical course of an ongoing therapeutic protocol. Yet, no evidence of effective application of AI tools in the setting of Impella support is available. On this background, we aimed at identifying possible future applications of AI-based tools in the setting of temporary MCS with an Impella device. We explored the state of research and development at the intersection of AI and Impella support and derived future potential applications of AI in routine Impella clinical management. We identified different areas where the future implementation of AI tools may contribute to addressing important clinical challenges in the setting of Impella support, including (i) early identification of the best suited pathway of care according to patients' conditions at presentation and intention to treat, (ii) prediction of therapy outcomes according to different possible therapeutic actions, (iii) optimization of device implantation procedures and evaluation of proper pump position over the whole course of support and (iv) prevention and/or rationale management of haemocompatibility-related adverse events. For each of those areas, we discuss the potential advantages, challenges and implications of harnessing AI-driven insights in the setting of MCS with an Impella device. Temporary MCS with an Impella device has great potential to benefit from the integration of AI-based tools. Such tools may indeed translate into groundbreaking innovation supporting clinical decision-making and therapy regulation, in particular in complex scenarios such as the multidevice MCS strategy.

IATROGENIC ACUTE MITRAL INSUFFICIENCY FOLLOWING IMPELLA–ASSISTED INTERVENTIONAL PROCEDURE

Abstract Background Short–term left ventricle mechanical assistance device could be useful in assist interventional cardiologist during high–risk procedures. Abiomed Impella is one of the most frequently used device in this respect due to the high flow available with a low rate of reported complications. Here we report a rare but potentially catastrophic complication related to the Impella device. Case Description A 78 years old patient was referred to our Division by a peripheral hospital for a severe, symptomatic (NYHA III) mitral regurgitation (MR) due to posterior mitral leaflet prolapse (with focal eversion of P3) and chordal rupture (Fig 1a). Medical history included a previous admission in the some hospital due to a scheduled Impella–assisted PTCA (left main/left anterior descending artery) . Pre–procedural trans–thoracic ECHO (TTE) did not show significant MR (Fig 1b). Results Patient underwent urgent surgical procedure. At operation postero–medial mitral commissure was seen to be completely everted with multiple rupture of P3 and A3 chordae. Surgical procedure (Fig 1c) included: P3 plication + posterior–medial commissure edge–to–edge plasty + complete mitral semi–rigid ring (Simulus) n.30. Left atrial appendage was also closed using an external Atriclip. Postoperative course was without significant complications except a superficial wound dehiscence which delayed hospital discharge till 20th postoperative day. Conclusion Despite being a feasible and attractive option for short–term mechanical circulation assistance during high–risk interventional procedure, Impella device insertion could cause significant mitral valve damage leading to clinical deterioration. Such potentially catastrophic complication should be, therefore, mandatory excluded before patient discharge following interventional procedure.

Are There Disparities in the Utilization of the Impella Device in Acute Myocardial Infarction and Cardiogenic Shock in the United States?

Are There Disparities in the Utilization of the Impella Device in Acute Myocardial Infarction and Cardiogenic Shock in the United States?

The Impella Device

The Impella small catheter like 6 inch long device which works on principle of submersible water pump. It is inserted in to heart without any surgical procedure it provides 2.5- 5.5 litters/min blood flow. Impella device is available in various types according to their location, size and flow rate. There are some indications of Impella device implantation cardiac failure, high risk percutaneous intervention, risk of bleeding, left ventricular failure ect. This device is contraindicated in some disease conditions like Left Ventricular Thrombus, Ventricular Septal Defect, Severe Peripheral Arterial Disease, Aortic Stenosis and Regurgitation, Mechanical Haemolysis, Peripheral Vascular Ischemia. In this article we provide information about Impella device. There are total 57 cases has done till 2019 were Impella 5.0 inserted in 14 cases via axillaries access. In 36 cases Impella CP inserted via percutaneous Trans femoral approach, but one, in a young patient, who due to the small calibre of his femoral artery required inter positioning of a 6 mm Dacron graft on his common femoral artery. In 07 cases Impella RP were implanted percutaneously through the femoral accesses.

Prehabilitation Maximizing Functional Mobility in Patients With Cardiogenic Shock Supported on Axillary Impella.

Physical therapy (PT) benefits for critically ill patients are well recognized; however, little data exist on PT in patients receiving temporary mechanical circulatory support. In this single-center retrospective study (February 2017-January 2022), we analyzed 37 patients who received an axillary Impella device (Abiomed, Danvers, MA) and PT to "prehabilitate" them before durable left ventricular assist device (dLVAD) implantation. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility tool assessed the functional status at different points during admission. Immediately after Impella placement, the median AM-PAC score was 12.7 (interquartile range [IQR], 9-15), and the scores continued to significantly increase to 18.4 (IQR, 16-23) before dLVAD and up to 20.7 (IQR, 19-24) at discharge, indicating improved independence. No PT-related complications were reported. Thus, we hypothesize that critically ill patients initially deemed equivocal candidates may safely participate in PT while maximizing functional activities before dLVAD placement.

Left atrial myxoma with cardiogenic shock following a myocardial infarction: a case report

BackgroundMyxomas are the most common primary cardiac tumor and typically originate in the left atrium. Atrial myxomas may present following complications of obstruction and emboli. If an atrial myxoma goes untreated, complications such as congestive heart failure, embolic stroke, and sudden death can occur.Case presentationA 58-year-old Caucasian male presented following a cardiac arrest. He was taken emergently to the cardiac catheterization lab and received two drug eluting stents. Following the procedure, he was found to have a left atrial mass that was intermittently obstructing the mitral valve on echocardiography. After leaving the cardiac catheterization lab, he was hypotensive and placed on multiple intravenous medications for hemodynamic support as well as an Impella device. Following medical optimization, he underwent one vessel coronary artery bypass graft as well as surgical excision of the left atrial mass, which pathology had shown to be an atrial myxoma.ConclusionThis patient’s case of cardiogenic shock following revascularization was complicated by the identification of an atrial myxoma, which, when large enough, can obstruct blood flow through the mitral valve leading to acute mitral dynamic stenosis. This condition results in circulatory collapse due to obstruction of the left ventricle in diastole as the myxoma occludes the mitral valve.

Structured Weaning From the Impella Left Ventricular Micro-Axial Pump in Acute Myocardial Infarction With Cardiogenic Shock and Protected Percutaneous Coronary Intervention: Experience From a Non-Cardiac Surgical Centre

The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction-cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined. We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters. Ten patients (eight male, two female; aged 43-70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C-E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4-48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%. A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol.

Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy

BackgroundThis study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization. MethodsPatients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality. ResultsThe median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01). ConclusionsCABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.

A Case of Myocardial Infarction with Non-obstructive Coronary Arteries Complicated by a Ventricular Septal Rupture: The Challenge of Achieving Hemodynamic Stability Using Impella Devices.

The prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is reported to be as worse as myocardial infarction with obstructive coronary arteries. However, its mechanical complications are still poorly understood. A 71-year-old woman developed MINOCA after ascending aortic replacement surgery. During treatment, the patient experienced cardiogenic shock due to a ventricular septal rupture (VSR). The introduction of Impella devices reduced the left-to-right shunt and improved the patient's hemodynamics. Finally, a scheduled surgical repair was performed under stable conditions. In this report, we focused on the pathophysiology of MINOCA-related VSR and discussed the effectiveness of Impella devices as a bridge to surgical repair and circulatory backup during the perioperative period.

Adding an extension piece to the end of the purge side arm of the Impella device can prevent the incidence of the cassette breaking and decrease the Impella device failure rate: Impact of practice change on patient outcome.

Background: Impella 5.5® with Smart Assist is a minimally invasive Left Ventricular Assist Devices (LVAD) approved by the Food and Drug Administration (FDA) for treating ongoing cardiogenic shock for up to 14 days. The Impella® intends to reduce ventricular workload and provide the circulatory support necessary for myocardial recovery.Research Question: Compared to standard practice, does adding an extension piece to the purge tube side arm of the Impella® Device decrease the incidence of device failure and positively impact the health outcome of adult patients receiving Impella® support?Study Design and Methods: A retrospective chart review of ICU patients was done at a tertiary care center from August 2018 to August 2022 to assess the differences in patient outcomes related to Impella® Device utilization before and after the implementation of the extension piece to the purge tube sidearm. Among patients reviewed, a total of 20 were included in our review, with seven not having the purge tube side arm extension added, while 13 patients had the extension.Results: The two study groups had no significant difference in patient health outcomes. Additionally, there were no instances of device failure requiring explanation without the extension tubing. However, there were no cases of the purge cassette cracking with the addition of the extension tubing.Conclusion: The addition of extension tubing to the purge cassette of the Impella® Device did not impact patient health outcomes or the incidence of device failure. There was a complete reduction in the incidence of the purge cassette cracking, which could reduce the potential for infection or device failure over a long period of mechanical support. There is a need for long-term prospective studies to confirm the results.

Impella device in fulminant myocarditis: Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD) registry analysis on outcomes and adverse events.

Given that fulminant myocarditis, characterized by unstable haemodynamics, is a significant clinical challenge and that traditional pharmacological treatments have limitations, evaluating alternatives such as the Impella device is a crucial focus of this study. Further, this study presents pioneering large-scale registry data on its use in managing fulminant myocarditis. Data from the Japanese Registry for Percutaneous Ventricular Assist Devices (J-PVAD) were analysed to assess Impella's role in managing fulminant myocarditis from February 2020 to December 2021. The primary outcome was 30-day mortality for those treated with Impella. Of the 269 patients treated with Impella, 107 used Impella standalone, and 162 used ECPELLA (Impella combined with extracorporeal membrane oxygenation). The average age was 54 years, with 42.8% females. Overall, 74.3% survived at 30 days. Specifically, the success rate was 68.5% for the ECPELLA group and 83.2% for the Impella standalone group. Cox regression highlighted that lower estimated glomerular filtration rate and pre-Impella systolic blood pressure increased adverse event risk, while Swan-Ganz catheterization use reduced it. Adverse events were noted in 48.7% of patients, such as bleeding (32.0%) and deteriorating renal function (8.6%). Impella's use in fulminant myocarditis demonstrates encouraging short-term outcomes, albeit with significant adverse events. These findings align with previous mechanical circulatory support studies, emphasizing caution regarding haemorrhagic issues. Further studies are essential to enhance patient selection and treatment approaches.