Microaxial Pump Research Articles

Combining Repeated VT Ablations with Axillary Transaortic Microaxial Left Ventricular Assist Device Support to Successfully Bridge to Heart Transplantation in a Patient with Recurrent Electrical Storm - A Case Report

<h3>Introduction</h3> End-stage heart failure is associated with high morbidity and mortality rates and can be complicated by sustained ventricular tachycardia (VT) with increased risk of ventricular fibrillation and sudden cardiac death. Transaortic microaxial left ventricular assist devices can be surgically implanted using an axillary approach and provide temporary mechanical circulatory support (tMCS). We report a case of combining repeated VT ablations with tMCS to successfully bridge to heart transplantation (OHT) in a patient with recurrent electrical storm. <h3>Case Report</h3> We report a case of a 66-year-old male with dilated cardiomyopathy due to myocarditis, who suffered a non-ST-elevation myocardial infarction due to three-vessel coronary artery disease. Despite urgent coronary bypass surgery, he showed no improvement of heart function and presented episodes of sustained VT. Due to poor RV function a durable left ventricular assist device was deemed not a suitable therapeutic strategy and he was evaluated for OHT. He underwent VT/premature ventricular contraction ablation in three areas of the right ventricular outflow tract (RVOT; free wall, posterolateral and HIS area). However, he suffered an intrahospital cardiac arrest with refractory cardiogenic shock and a resuscitation time of 75 minutes with subsequent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation. Following the surgical implantation of a transaortic microaxial pump, the VA-ECMO was successfully weaned. He showed good neurological outcome and underwent physiotherapy with full mobilization and ambulation on the ward. Under hemodynamic support he underwent another high-risk VT ablation and concomitant stellate ganglion blockade and postprocedural stable sinus rhythm was achieved. After 34 days of tMCS the patient underwent OHT. Postoperative course was uneventful. 13 days after OHT he was discharged to a rehabilitation facility, after which he was discharged home after three weeks. <h3>Summary</h3> In patients with end-stage heart failure and recurrent electrical storm a surgically implanted transaortic microaxial pump can allow hemodynamic stabilization during high-risk procedures such as VT ablation and neuromodulation as a feasible bridge to OHT strategy.

Axillary transvalvular microaxial pump as extended bridge to transcatheter aortic valve replacement in cardiogenic shock with severe aortic stenosis

Cardiogenic shock in the setting of severe aortic stenosis is associated with poor outcomes. We describe 5 patients with cardiogenic shock and severe aortic stenosis who received an axillary microaxial pump (Impella) as an extended bridge to transcatheter aortic valve replacement. The median (range) age was 65 (61-87) years old, 80% were male, and 80% presented with stage D or E cardiogenic shock. In most cases, balloon aortic valvuloplasty was performed prior to pump insertion. Stabilization by Impella allowed for heart team evaluation and additional interventions, including percutaneous coronary intervention, MitraClip, and cardioversion. After a median (range) of 7 (5-14) days of Impella support, semi-elective transcatheter aortic valve replacement was successfully performed. All patients survived to discharge. Four patients (80%) were alive beyond 1 year. In these high-risk patients, prolonged support with a microaxial pump allowed for stabilization, ancillary interventions, and multi-disciplinary heart team evaluation prior to transcatheter aortic valve replacement.

Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy

ABSTRACT Introduction Trans-valvular micro-axial flow pumps such as Impella are increasingly utilized in patients with cardiogenic shock [CS]. A number of different Impella devices are now available providing a wide range of cardiac output. Among these, the Impella 5.0 and recently introduced Impella 5.5 pumps can provides 5.55 L/min of flow, enabling complete left ventricular support with more favorable hemodynamic effects on myocardial oxygen consumption and left ventricular unloading. These devices require placement of a surgical conduit graft for endovascular delivery, but are increasingly being used in patients with CS due to acutely decompensated heart failure [ADHF], acute myocardial infarction [AMI] and after cardiac surgery as a bridge to transplant or durable ventricular assist device surgery or myocardial recovery. Areas Covered This review focuses on the device profile and use of the Impella 5.0 and 5.5 systems in patients with CS. Specifically; we reviewed the published literature for Impella 5.0 device to summarize data regarding safety and efficacy. Expert Opinion The Impella 5.0 and 5.5 are trans-valvular micro-axial flow pumps for which the current data suggest excellent safety and efficacy profiles as approaches to provide circulatory support, myocardial unloading, and axillary placement enabling patient mobilization and rehabilitation. Abbreviations pMCS, Percutaneous mechanical circulatory support devices; CS, Cardiogenic shock; ADHF, Acute decompensated heart failure; AMI, Acute myocardial infarction; LVAD, Left ventricular assist deviceI; ABP, Intra-aortic balloon pump; VA-ECLS, Veno-arterial extracorporeal life support

Abstract 11816: Combined Use of VA-ECMO and IMPELLA (ECPELLA) Reduces Myocardial Damage and Mortality in Lethal Cardiogenic Shock Patients Due to Acute Coronary Syndrome

Background: Short-term mortality of lethal cardiogenic shock (CS) patients due to acute coronary syndrome (ACS) remains to be improved. The veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been applied as the effective lifesaving modality for CS patients. While VA-ECMO maintains end-organ perfusion, it increases the damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides the systemic circulatory support and LV unloading. However, it remains unknown whether LV unloading effect by ECPELLA can reduce the myocardial damage and the mortality. Purpose: This study was to assess whether ECPELLA reduces myocardial damage and improves the mortality of CS patients due to ACS. Methods: From January 2012 to May 2021, 66 consecutive patients with lethal CS (SCAI stage-E) due to ACS were enrolled. All patients received VA-ECMO support prior to or after the percutaneous coronary intervention. Among them, 34 patients received ECPELLA and 32 patients received VA-ECMO + IABP. We assessed serum CK-MB levels and the cumulative 30-day mortality. Results: There were no significant difference in age, rate of male sex, coronary risk factors, ST elevated ACS, left main trunk (LMT) lesion, and the time from onset to reperfusion between two treatment groups. The ECPELLA group had significantly lower peak CK-MB and lower 30-day all-cause mortality compared to the VA-ECMO + IABP group [Peak CPK level: median (IQR); 295 (92-507) vs.580 (219-1090): p=0.002, the 30-day mortality rate: 50% vs. 76%: p=0.02, respectively]. Multivariate Cox proportional hazard analysis including age, the time form onset to reperfusion, LMT lesion, E-CPR, and ECPELLA revealed that the ECPELLA (HR: 0.30 95% confidence interval:0.13-0.64; p=0.002) was independently associated with the 30-day all-cause mortality. Conclusion: Results suggest that the ECPELLA reduces the myocardial damage shown by peak CK-MB and improves the 30-day mortality.

Abstract 12052: A Comprehensive Simulation-Based Training for E-CPR Improves the Neurological Outcome of Patients With Refractory Cardiac Arrest

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with refractory cardiac arrest (CA). To improve the outcome of E-CPR, we developed a comprehensive simulation-based E-CPR training program. In the present study we assessed whether the E-CPR training improved the mortality and the neurological outcome. Methods: We have implemented the comprehensive E-CPR simulation training program twice a year to the medical team, which consists of emergency physicians, cardiologists, nurses, clinical engineers, and radiographers using a mock vascular model for E-CPR (ECMO cannulation). We assessed collapse to ECMO time, cumulative 30-day survival and good neurological outcome at hospital discharge defined as the cerebral performance categories (CPC) of 1 or 2. Results: Fifty-three consecutive patients received E-CPR for OHCA from January 2012 to December 2020 in which 31 patients were prior to (until September 2017) and 22 were after (from October 2017) the initiation of the E-CPR training. No differences were found in age, rates of witnessed and bystander-CPR, shockable rhythms, or acute coronary syndrome (ACS). Intra-aortic balloon pump was used in 87% patients prior to and 27% patients after the training (p&lt;0.001), and a microaxial Impella pump was used in 55% after the training. Collapse to ECMO time was significantly shorter after the training (p&lt;0.001). Cumulative 30-day survival and the rate of favorable neurological outcome were significantly higher after the training (p&lt;0.05). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.38 (10 years increase), 95% confidence interval [CI], 1.12-1.73, p=0.002), Collapse to ECMO time (HR, 1.14, 95%CI, 1.04-1.23, p=0.006), and additional Impella use (HR, 0.23, 95% CI, 0.08-0.69, p=0.0009) were significantly associated with the 30-day survival. Conclusions: The E-CPR training significantly improved the collapse to ECMO time. The faster deployment of ECMO improves the neurological outcome and 30-day survival in patients with refractory CA. Additional use of Impella may improve the survival.

Abstract 9777: Acute Anemia and Outcomes in ACS Treated with Mechanical Circulatory Support

Introduction: Anemia increases mortality in acute coronary syndromes (ACS). Mechanical circulatory devices (MCS) are known to cause anemia due to mechanical shearing, but there is limited data evaluating the prognostic significance of anemia in ACS patients treated with MCS. Methods: A single center retrospective cohort study included 210 consecutive ACS (56% STEMI) patients treated with MCS (IABP in 73%, 27% micro-axial pump Impella®) based on the clinical need. Clinical characteristics, hospital course details, and outcomes were obtained from the electronic health records. Results: The study cohort included 76% males, 66.9±10.9 years old, with atrial fibrillation (AF) in 9%, HTN in 43%, CHF in 37%, CAD in 42%, CABG in 40%, diabetes in 24%, COPD in 8%, and stroke in 6%. Average MCS duration was 4.0±2.8 days, with vascular complications in 17%, bleeding in 42%, transfusion in 40%, and kidney replacement therapy (KRT) in 15%. All-cause mortality was 16.2% with mean time to death of 11.2±1.2 days. There were no differences in pre-MCS Hgb between expired patients and survivors (12.3±2.6 vs. 12.8±2.2 g/dL, p=0.197). Post-MCS 24-hour Hgb was significantly lower in the expired patients (10.4+/-2.4 vs. 11.7+/-2.3, p=0.003) and in patients with prior CAD (11.1+/-2.1 vs. 11.8+/-2.5, p=0.037), while sex, AF, HTN, CABG, DM, COPD, or stroke did not affect Hgb. Admission shock (HR 4.7, 95%CI 2.087-10.783, p&lt;0.001) and KRT (HR 5.4, 95%CI 2.331-12.667, p&lt;0.001) decreased survival, while higher 24-hour Hgb (HR=0.74, 95% CI: 0.61-0.90, p=0.002) and higher presentation GFR (HR 0.968, 95%CI 0.948-0.989, p=0.003) improved survival. Transfusion did not affect mortality (18% vs. 15% in non-transfused patients, p=0.549). In a multivariate analysis, admission shock (HR 2.9, 95%CI 1.192-7.059) and KRT post MCS (HR 3.876, 95%CI 1.574-9.546, p=0.003) remained predictive of reduced survival, while Hgb and GFR were not important. Conclusion: Acute anemia in ACS patients treated with MCS is not prognostically significant. It remains unclear whether there is an optimal hemoglobin level which could alter the prognosis. Ongoing trials (MINT) are evaluating the optimal strategy of managing anemia in AMI.

Percutaneous coronary intervention on combined VA-ECMO and IMPELLA (ECPELLA) support may reduce myocardial damage in cardiogenic shock patients with STEMI who required mechanical circulatory support

Abstract Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapeutic modality for patients with cardiogenic shock (CS) including STEMI. The VA-ECMO maintains end-organ perfusion, however, it significantly increases damaged left ventricular (LV) afterload. Combined treatment of VA-ECMO and a micro-axial Impella pump, ECPELLA, simultaneously provides systemic circulatory support and LV loading reduction (LV unloading). Studies in ischemic animal models displayed that LV unloading reduced myocardial size. However, it remains unknown whether LV unloading effect by ECPELLA during percutaneous coronary intervention (PCI) can reduce myocardial damage in human STEMI patients with severe cardiogenic shock. Purpose This study was to assess whether PCI on ECPELLA support can reduce myocardial damage in STEMI patients with severe cardiogenic shock. Methods Sixteen consecutive patients with STEMI and lethal CS (SCAI stage E) were enrolled. All patients suffered from cardiac arrest. Fifteen patients (94%) underwent extracorporeal cardiopulmonary resuscitation using VA-ECMO. From October 2018 to November 2019, PCI was carried out on VA-ECMO support and the mechanical circulatory support (MCS) modality during PCI was switched to ECPELLA since December 2019. There were 8 patients who underwent PCI on ECPELLA support (ECPELLA-PCI) and 8 patients who underwent PCI on single VA-ECMO support (ECMO-PCI). All patients in ECMO-PCI group were escalated to ECPELLA after PCI. Therefore, the difference between groups was timing of LV unloading, i.e., pre-PCI or post-PCI condition. We assessed total MCS flow during PCI, and peak and time course changes in CK-MB levels from days 0 to 3. Results There were no significant differences in age, rate of male sex, body surface area, shockable rhythm, serum lactate levels, and door to MCS time. Patients in ECPELLA-PCI had significantly longer door to recanalization time (73min in ECPELLA vs. 49min in VA-ECMO, p&amp;lt;0.05), and higher total MCS flow during PCI (3.1 L/min/sqM vs. 2.0 L/min/sqM, p&amp;lt;0.05). Peak and the area under the curves (AUC) from day 0 to day 3 of CK-MB in ECPELLA-PCI were significantly lower than ECMO-PCI group (peak CK-MB 120 vs. 524 IU/L and CK-MB AUC 143 vs. 464 IU/L*Day, respectively, p&amp;lt;0.05). While all patients received red blood cell (RBC) and plasma (PL) transfusions, ECPELLA-PCI required larger amount of RBC and PL transfusions (p&amp;lt;0.05). Conclusion The ECPELLA-PCI appeared to reduce myocardial damage shown by peak and AUC of CK-MB levels. Lager amount of blood transfusion is a major drawback of this treatment modality. Further studies are necessary whether ECPELLA-PCI is an effective revascularization approach for myocardial damage reduction with favorable mid- and long-term outcome in patients with STEMI with severe cardiogenic shock. Funding Acknowledgement Type of funding sources: None. Total MCS FLow and Ttoal MCS flow indexPeak CK-MB and CK-MB AUC

Feasibility and Safety of an 8 F Angioseal® Vascular Closure Device for Closure of Large Bore Impella CP® Access

Purpose: Percutaneous mechanical circulatory support (pMCS) with the Impella® device is routinely used in cardiogenic shock and high risk percutaneous coronary interventions (PCI). However, safety and feasibility to close the large bore access (LBA) post-hoc remain a challenge. Materials and Methods: In patients with planned termination of Impella therapy, corresponding LBA closure was attempted using an undersized AngioSeal® device, which was deployed after insertion of a 0.035 in J-wire through the guidewire access port. Cross-over angiographic visualization before and after deployment as well as in-hospital follow up were performed to assess closure success and screening for short-term adverse events. Results: We evaluated 17 patients (68 year old, IQR 58–76, 71% male) in whom 14 F LBA closure after pMCS using the Impella CP® was achieved with an undersized AngioSeal® device. Clinical indication for pMCS was cardiogenic shock in 94% and protected PCI in 6%. Impella CP® devices were withdrawn after a median of 4 days (IQR 3–6 days). Primary hemostasis was achieved in the majority of patients (14/17; 82%) while single cross-over balloon inflation led to hemostasis in the remaining patients. One patient suffered acute ischemia later in the course of the disease, but this was not directly related to the closure device. In this study, no major bleeding or other device-related adverse events were observed. Conclusion: The 8 F AngioSeal® vascular closure device has been safely used for removal of the Impella CP® microaxial pump in most cases of predominantly normal weight patients. This technique may be considered feasible for post-hoc LBA closure in the context of pMCS, especially when preclosure options are not suitable or unavailable.

Unloading in Refractory Cardiogenic Shock After Out-Of-Hospital Cardiac Arrest Due to Acute Myocardial Infarction-A Propensity Score-Matched Analysis.

Aims: Unclear neurological outcome often precludes severely compromised patients after out-of-hospital cardiac arrest (OHCA) from mechanical circulatory support (MCS), while it may be considered as rescue therapy for patients with refractory cardiogenic shock (rCS) in the absence of OHCA. This analysis sought to investigate the role of left ventricular (LV) unloading in patients with rCS related to acute myocardial infarction (AMI) after OHCA.Methods: Of 273 consecutive patients receiving microaxial pumps in the Hannover Cardiac Unloading Registry between January 2013 and August 2018, 47 presented with AMI–rCS following successful resuscitation. Subsequently, the patients were compared by propensity score matching to patients with OHCA AMI–rCS without MCS. The patient data for OHCA without LV unloading was available from 280 patients of the Hannover Cooling Registry for the same time period. Furthermore, the patients with OHCA without rCS were compared to the patients with OHCA AMI–rCS and LV unloading.Results: In total, 15 OHCA AMI–rCS patients without MCS were matched to patients with AMI–rCS and Impella. Patients without LV support had a higher proportion of a cardiac cause of death (n = 7 vs. n = 3; p = 0.024). LV unloading with Impella counteract rCS status and was associated with a preferable 30-day survival (66.7 vs. 20%, p = 0.01) and a favorable neurological outcome after 30 days (Cerebral Performance Category ≤2, 47 vs. 27%). Impella support is associated with a higher 30-day survival (odds ratio, 2.67; 95% confidence interval, 1.02–13.66).Conclusion: In patients after OHCA with AMI–rCS, Impella support incorporated in a strict standardized treatment algorithm results in a preferable 30-day survival and counteracts severe rCS status.

Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality.

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p < 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.

Combined extracorporeal membrane oxygenation and microaxial pump-when left ventricular preload is too low to unload in cardiogenic shock.

PurposeSevere cardiogenic shock is the major driver of mortality on cardiologic intensive care units. Novel therapeutic options like extracorporeal membrane oxygenation (ECMO) or the combination of ECMO and a percutaneous microaxial pump like Impella CP (ECMELLA) are promising Options. Here we want to focus on the question what happens when left ventricular preload is too low to unload in cardiogenic shock in patients with ECMELLA and this aspect is illustrated by transesophageal echocardiography.MethodsWe detail a case of a 43‐year‐old active smoker who was admitted for acute myocardial infarction causing severe cardiogenic shock and who was finally treated with ECMELLA. Transesophageal echocardiography is used to illustrate what happens when left ventricle (LV) preload is too low to unload.ResultsTransesophageal echocardiography demonstrates complete collapse of LV and LA as consequence of increased but still low flow rate of the coaxial pump.ConclusionNovel therapeutic options like ECMO and percutaneous microaxial pumps like Impella CP, 5.0 or the combination of both (ECMELLA), are promising options. Whether these approaches reduce mortality has to be evaluated in urgently needed randomized trials but results will not be available in the next few years.

Coronary artery bypass grafting under sole Impella 5.0 support for patients with severely depressed left ventricular function

Selection of the ideal surgical procedure for coronary revascularization in patients with severe cardiac dysfunction at times may represent a challenge. In recent years, with the advent of surgical large microaxial pumps, e.g., Impella 5.0 (Abiomed Inc., Boston, USA), specific support and effective unloading of the left ventricle has become available. In the interventional field, good results have been achieved with smaller microaxial pumps in the setting of so-called protected percutaneous coronary intervention. In this study, we would like to share our early experience with surgical coronary revascularization under the sole support of Impella 5.0, omitting the use of heart–lung machine in three cases of severe cardiac dysfunction due to complex ischemic heart disease. Effective circulatory support intraoperatively and postoperatively speaks in favor of this technique in selected patients.

To Vent or Not to Vent: A Loaded Question During Venoarterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

To Vent or Not to Vent: A Loaded Question During Venoarterial Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock

Impella 5.5 Direct Aortic Implant and Explant Techniques

The Impella 5.5 with SmartAssist system (Abiomed, Danvers, MA) is approved for the treatment of cardiogenic shock after acute myocardial infarction, cardiac surgery, or in the setting of cardiomyopathy. Designed for full circulatory support and left ventricular unloading the system comprises a catheter-based microaxial pump placed across the aortic valve, pulling blood from the left ventricle and into the ascending aorta. Implantation can be approached through the axillary artery or directly into the aortic root. We present several technical options for implanting, tunneling, and explanting the system using the direct aortic approach and allowing for bedside removal.

Percutaneous Axillary Access for Placement of Microaxial Ventricular Support Devices

Background: There has been increasing utilization of short-term mechanical circulatory support devices for a variety of clinical indications. Many patients have suboptimal iliofemoral access options or reasons why early mobilization is desirable. Axillary artery access is an option for these patients, but little is known about the utility of this approach to facilitate short-term use for circulatory support with microaxial pump devices. Methods: The Axillary Access Registry to Monitor Safety (ARMS) was a prospective, observational multicenter registry to study the feasibility and acute safety of mechanical circulatory support via percutaneous upper-extremity access. Results: One hundred and two patients were collected from 10 participating centers. Successful device implantation was 98% (100 of 102). Devices were implanted for a median of 2 days (interquartile range, 0–5 days; range, 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. There were 3 patients with brachial plexus–related symptoms all consisting of C8 tingling and all arising after multiple days of support. Postprocedural access site hematoma or bleeding was noted in 9 patients. Device explantation utilized closure devices alone in 61%, stent grafts in 17%, balloon tamponade facilitated closure in 15%, and planned surgical explant in 5%. Duration of support appeared to be independently associated with a 1.1% increased odds of vascular complication per day ([95% CI, 0.0%–2.3%] P =0.05). Conclusions: Percutaneous axillary access for use with microaxial support pumps appears feasible with acceptable rates of bleeding despite early experience. Larger studies are necessary to confirm the pilot data presented here.

Abstract 268: Combined Use of VA-ECMOecmo and Impella (ECPELLA) Improves Outcome of Patients with Out of Hospital Cardiac Arrest or Cardiac Arrest at the Emergency Room

Background: Extracorporeal CPR (E-CPR) is a lifesaving method for refractory cardiac arrest (CA), and IABP has been often used as the additional circulatory support. However, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) increase damaged left ventricular (LV) afterload. The percutaneous microaxial pump, IMPELLA, can reduce damaged LV preload and afterload with circulatory support. Concomitant use of VA-ECMO and IMPELLA (ECPELLA) may have significant effect on clinical outcome. Objective: This study is to evaluate the effects of ECPELLA on clinical outcome of patients with out of hospital cardiac arrest (OHCA) or CA at the emergency room (ERCA) who underwent E-CPR. Method: We retrospectively reviewed 140 consecutive patients who underwent E-CPR from January 2012 through May 2020 in our institute. Seventy-four in-hospital CA patients were excluded, and 66 patients with OHCA or ERCA were recruited. Patients were divided into three groups ECEPLLA (n=13), ECMO with IABP (n=40), and ECMO alone (n=13). The primary endpoint was 30-day mortality. Secondary endpoint was good neurological outcome at hospital discharge defined as cerebral performance categories (CPC) of 1 or 2. Result: There were no significant differences in age, sex, OHCA, acute coronary syndrome in all three groups. The rate of shockable rhythm was higher in the ECPELLA and ECMO with IABP groups than ECMO alone. ECPELLA had the shortest time from CA to ECMO support compared with other groups. The 30-day survival and favorable neurological prognosis rates were significantly higher in the ECPELLA group, compared with other groups (ECPELLA: 61% vs. IABP: 18% vs. ECMO alone: 15%; P=0.008, ECPELLA: 38% vs. IABP: 8% vs. ECMO alone: 8%; P=0.03). Multivariate cox regression analysis including age, sex, time from CA to ECMO support and ECPELLA revealed that age (hazard ratio [HR], 1.36 (10 years increase), 95% confidence interval [CI], 1.11-1.67, P=0.04), male (HR, 2.42, 95%CI, 1.04-5.66, P=0.04), time from CA to ECMO support (HR, 1.01, 95%CI, 1.01-1.03, P=0.04), and ECPELLA (HR, 0.35, 95%CI, 0.13-0.91, P=0.03) were significantly associated with 30-day mortality. Conclusion: ECPELLA could improve 30-day mortality and neurological outcome in OHCA or ERCA patients who underwent E-CPR.

Currently Available Options for Mechanical Circulatory Support for the Management of Cardiogenic Shock.

Cardiogenic shock (CS) is a complex condition with a high risk for morbidity and mortality. Mechanical circulatory support (MCS) devices were developed to support patients with CS in cases refractory to treatment with vasoactive medications. Current devices include intra-aortic balloon pumps, intravascular microaxial pumps, percutaneous LVAD, percutaneous RVAD, and VA ECMO. Data from limited observational studies and clinical trials show a clear difference in the level of hemodynamic support offered by each device. However, at this point, there are insufficient clinical trial data to guide MCS selection and, until ongoing clinical trials are completed, use of the right device for the right patient depends largely on clinical judgment.

Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock.

Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.

The Physiologic Basis and Clinical Outcomes of Combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides effective hemodynamic support in cardiogenic shock, but in some cases may be complicated by left ventricular (LV) distension and pulmonary edema. The Impella, a catheter-mounted microaxial pump has been used to unload the LV. Recent studies have compared the clinical outcomes of VA-ECMO to the combination of Impella and VA-ECMO. The purpose of this review is threefold: firstly, to discuss the physiological effects of Impella support in addition to VA-ECMO, secondly to review published studies on the outcome of this combined support, and thirdly to provide a practical overview of the approach to combining Impella and VA-ECMO.Electronic supplementary materialThe online version of this article (10.1007/s40119-020-00175-6) contains supplementary material, which is available to authorized users.

Influence of Timing and Predicted Risk on Mortality in Impella-Treated Infarct-Related Cardiogenic Shock Patients.

Background: In-hospital mortality in acute myocardial infarction-related cardiogenic shock (AMI-CS) remains high. The only adequately powered randomized trial showed no benefit of routine use of the intra-aortic balloon pump in AMI-CS. We compared individually predicted mortality using CardShock- and IABP-Shock II-scores in AMI-CS patients treated with an Impella microaxial pump, who met the IABP-Shock II-trials inclusion/exclusion criteria, to observed mortality on circulatory support in order to determine whether standardized use of an Impella microaxial flow-pump in AMI-CS is associated with lower than predicted mortality rates and whether timing of implantation or selecting patients based on predicted risk is meaningful.Methods and Results: We analyzed data from 166 consecutive Impella-treated AMI-CS patients meeting the inclusion/exclusion criteria of the IABP-Shock II-trial (age 64 ± 11 years). Thirty-nine percentage of 64 patients had been resuscitated before Impella implantation. Overall 30-day mortality was 42%. Mortality was higher in resuscitated patients (50 vs. 36%, p = 0.0452) and when Impella was implanted post-PCI (Impella-pre-PCI: 28%, Impella-post-PCI: 51%, p = 0.0039). While in both score systems there was no significant difference between predicted and observed overall 30-day mortality, predicted mortality was significantly higher than observed mortality on Impella support only for individuals with highest predicted risk based on CardShock score (predicted 77 vs. observed 51%, p = 0.025).Conclusions: Our retrospective analysis suggests that the use of the Impella microaxial pump may be effective in selected cases of high risk patients with AMI-CS.Condensed abstract: Mortality is high in acute myocardial infarction-related cardiogenic shock despite rapid revascularization. Haemodynamic support with an intraortic balloon pump does not reduce mortality. In this retrospective registry including 166 consecutive IABP-Shock II-eligible cardiogenic shock patients in four dedicated shock centers, observed mortality on circulatory support with an Impella was significantly lower than predicted in patients with highest mortality risk. Implantation prior to PCI in acute myocardial infarction-related cardiogenic shock seemed to be associated with lower mortality than implantation post PCI.