Use of Impella Ventricular Assist Device in Patients with Severe Coronary Artery Disease Presenting with Cardiac Arrest

Impella (Abiomed, Danvers, MA) is a percutaneously inserted ventricular assist device (VAD). It has been increasingly used in patients with severe heart failure, cardiogenic shock, and high-risk percutaneous intervention (PCI). However, the use and efficacy of Impella in patients with severe coronary artery disease (CAD) presenting with cardiac arrest has rarely been reported.The objective of this study is to report our center experience in using Impella VAD in CAD patients presenting with cardiac arrest. From December 2010 to March 2011, three patients with severe CAD presented to our center with cardiac arrest underwent PCI with Impella support. We reported three cases of severe CAD presenting with cardiac arrest successfully treated with PCI and Impella support. Our experience demonstrated that Impella VAD may play an adjunctive role in obtaining hemodynamic stability in these high-risk patients undergoing PCI. One of the patients was supported to left VAD implantation, and the other two had excellent neurological and functional recovery. Our reports suggest an important role of Impella in cardiac arrest population. Earlier Impella implantation after cardiac arrest might provide cardiac support and tissue perfusion until recovery or high-risk PCI.     

A method for maintaining vascular access when Impella exchange is required

A 45‐year old male with no prior cardiac history, presented with cardiogenic shock in the setting of an anterolateral ST elevation myocardial infarction. We first placed a 2.5 Impella for hemodynamic support, and proceeded with emergent percutaneous coronary intervention to the proximal LAD. Several hours following percutaneous coronary intervention (PCI), the patient became acutely hypotensive and an echocardiogram revealed the Impella catheter was kinked within the left ventricle. The patient was taken back to the cath lab for Impella adjustment; however, damage to the distal catheter required the Impella be exchanged. As the patient was therapeutically anticoagulated and on dual antiplatelet therapy, we modified the Impella catheter in order to maintain existing vascular access during Impella exchange. This case demonstrates our method for maintaining vascular access during Impella exchange, thereby eliminating the need for a second arterial puncture. © 2017 Wiley Periodicals, Inc.     

First Canadian experience with high-risk percutaneous coronary intervention with assistance of a percutaneously deployed left ventricular assist device

Mechanical assist devices play an increasing role in high-risk percutaneous coronary intervention (PCI) in highly complex and critically ill patients. The Impella Recover LP 2.5 is a minimally invasive left ventricular assist device that is inserted percutaneously via a 13 Fr sheath. The device is engineered to provide a significant increase in cardiac output in patients with severe left ventricular impairment as well as in patients undergoing high-risk coronary intervention, and may provide substantive circulatory support when severe hemodynamic compromise occurs. It can potentially be maintained in situ for five to seven days. Canada's first implantations of an Impella device providing circulatory support in patients undergoing complex, high-risk PCI are reported. Larger studies will be required to identify whether a survival benefit or improvement in left ventricular function can be achieved when using the Impella device to support patients undergoing high-risk PCI or those in cardiogenic shock.     

Single stick access using a VA-ECMO arterial return cannula for coronary intervention in cardiogenic shock

Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is growing exponentially for cardiogenic shock and cardiac arrest, and many of these patients require percutaneous coronary intervention (PCI). In some cases, radial arterial access may not feasible among patients with peripheral vascular disease or if larger diameter guide catheters are required. Further, VA-ECMO is commonly used in combination with an intra-aortic balloon pump or Impella, thereby limiting vascular access options and increasing the risk of vascular complications including bleeding and limb ischemia. For these reasons, new approaches to perform PCI without the need for an additional arterial puncture are required. We describe a case of a 70-year-old man with cardiogenic shock referred for high-risk PCI while supported with VA-ECMO and an Impella CP and illustrate a novel method for single-stick access for PCI through the return cannula of the VA-ECMO circuit.     

Use of Left Ventricular Support Devices During Acute Coronary Syndrome and Percutaneous Coronary Intervention

In an effort to improve outcomes in percutaneous coronary intervention (PCI), percutaneous ventricular assist devices (PVADs) have been investigated in (1) high-risk PCI, (2) acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) and (3) in AMI without CS. PCI has become an increasing complex due to an ageing population with complex disease and the frequent presence of impaired LV function. Patients undergoing high-risk PCI in these circumstances are prone to acute cardiovascular collapse. Additionally, mortality in AMI complicated by CS remains high. Lastly, LV support during AMI may reduce infarct size and therefore preserve LV function. At present, four commercially available devices exist: intra-aortic balloon pump counterpulsation (IABP), Impella, TandemHeart and extracorporeal membrane oxygenation (ECMO). These devices are employed in an effort to increase cardiac output, mean arterial pressure (MAP) and coronary perfusion and to reduce pulmonary capillary wedge pressure (PCWP). The mechanism of action differs with each device, and there are advantages and disadvantages. In this update, we discuss recent data describing the use of PVADs to support patients with AMI with or without cardiogenic shock and during high-risk PCI. We focus on the unique features of each device, highlighting strengths, weaknesses and frequently encountered complications, which may be important when tailoring the most appropriate PVAD therapy to an individual patient’s need.     

Use of Impella Recover 2.5 left ventricular assist device in patients with cardiogenic shock or undergoing high-risk percutaneous coronary intervention procedures: experience of a high-volume center

AIM: Percutaneous coronary interventions are increasingly applied to high-risk patients. The availability of hemodynamic support devices offers a promising option to prevent and treat low-output syndrome in these patients. The aim of this study was to evaluate the feasibility, safety and efficacy of the Impella Recover' LP 2.5 left ventricular assist device in patients with cardiogenic shock or undergoing high-risk percutaneous coronary interventions. METHODS: Eleven patients presenting cardiogenic shock (N=6) or scheduled for high-risk percutaneous revascularization (N=5) were evaluated. The Impella pump was successfully implanted in all patients, except one. When implanted, the device was correctly positioned in the left ventricle and remained in a stable position. RESULTS: Bleedings occurred in 7 patients (5 of them presented cardiogenic shock), while renal failure and severe thrombocytopenia were observed in 4 and 1 patients respectively, all with cardiogenic shock. During high-risk procedures, the Impella pump succeeded in obtaining hemodynamic stability, while in only two patients with cardiogenic shock the device determined a significant improvement of hemodynamic variables. All elective patients and two patients with cardiogenic shock were discharged from the hospital and were still alive at 30-day follow-up. CONCLUSION: These data, although preliminary due to the limited sample size, demonstrated the feasibility, safety and efficacy of the Impella Recover(R) LP 2.5 during high-risk percutaneous procedures, even though the benefits of prophylactic deployment of such a system have to be further investigated. The use of Impella Recover(R) LP 2.5 in patients with cardiogenic shock is feasible and safe, however it maybe insufficient in reversing an advanced cardiogenic shock which, probably, has to be treated with more powerful left ventricular assist devices.     

Percutaneous left ventricular support devices

Patients undergoing percutaneous coronary intervention (PCI) who have severely compromised left ventricular systolic function and complex coronary lesions including multivessel disease, left main disease, or bypass graft disease are at higher risk of adverse outcomes from hemodynamic collapse. The TandemHeart percutaneous left ventricular assist device and the Impella Recover LP 2.5 System may provide rapid circulatory support in high-risk PCI patients and in those who have cardiogenic shock. Identification of patients who are at high risk for severe hemodynamic compromise and most likely to benefit from mechanical circulatory support is crucial to derive the most benefit from this therapy. Multicenter randomized clinical trials are needed to clearly define the role of these two devices in providing circulatory support in a variety of clinical settings.     

Unmasking right ventricular failure in cardiogenic shock: The importance of serial hemodynamics

A 65-year-old female was transferred with myocardial infarction, three-vessel coronary artery disease, cardiogenic shock and an intraaortic balloon pump. Given persistent shock, mechanical circulatory support (MCS) was upgraded using a left ventricular hemodynamic support device (Impella CP). The patient was monitored in the catheterization laboratory and serial hemodynamic measures were obtained. Initial hemodynamics showed relative improvement; however, serial assessments demonstrated worsening hemodynamics secondary to right ventricular failure, ultimately requiring a right ventricular hemodynamic support device. The case highlights the rapid changes that can occur with mechanical circulatory support devices and demonstrates the importance of obtaining serial hemodynamics in the cardiac catheterization laboratory.     

Combined use of impella device and intra‐aortic balloon pump to improve survival in a patient in profound cardiogenic shock post cardiac arrest

Patients who suffer cardiogenic shock after cardiac arrest have a very poor prognosis. Left ventricular assist devices have proven to be useful in these patients to improve survival. Recently introduced percutaneous assist devices are easier to use and can be inserted quickly in the catheterization laboratory. We describe a case where intra‐aortic balloon pump by itself was not enough to provide hemodynamic support in a patient with cardiogenic shock after cardiac arrest. The Impella Recover^® LP 2.5 system (ABIOMED, Inc., Danvers, MA) was successfully used along with the balloon pump for hemodynamic support and resulted in dramatic improvement of the patient's condition. © 2009 Wiley‐Liss, Inc.     

急诊介入治疗合并院前心脏骤停急性心肌梗死疗效观察

目的 评价急诊经皮冠状动脉介入治疗(PCI)合并院前心脏骤停急性ST段抬高型心肌梗死(STEMI)的临床疗效.方法 入选2004年9月至2008年11月接受急诊PCI的STEMI患者1446例,其中合并院前心脏骤停患者(心脏骤停组)49例,无院前心脏骤停患者(无心脏骤停组)1397例.分析患者住院期间和出院后1年的临床情况,包括总病死率、心脏不良事件、卒中及出血事件等.结果 与无心脏骤停组比较,心脏骤停组急诊PCI成功率差异无统计学意义(88.8%比85.7%,P=0.497),住院期间心原性休克(3.0%比22.4%,P＜0.001)和心脏骤停(5.9%比44.9%,P＜0.001)的发生率较高,住院期间总病死率较高(2.0%比36.7%,P＜0.001).发病至院外抢救时间、心脏骤停时心律为心室停顿、入院时Glasgow昏迷评分≤7分和人院时心原性休克是心脏骤停组患者住院期间死亡的独立危险因素.随访1年显示,无心脏骤停组与心脏骤停组总病死率(6.5%比6.9%)、再次心肌梗死(1.4%比3.4%)、再次血运重建(3.4%比6.9%)和卒中发生率(6.4%比6.9%)差异均无统计学意义.结论 与无院前心脏骤停STEMI患者比较,合并院前心脏骤停STEMI患者住院期间病死率较高,但是急诊PCI后1年的疗效相似.     

The role of extracorporeal membrane oxygenation in emergent percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock and cardiac arrest

Patients with myocardial infarction (MI) who have out-of-hospital cardiac arrest and cardiogenic shock have a high mortality rate. Although intra-aortic balloon counterpulsation is frequently used in patients with cardiogenic shock, it does not provide complete hemodynamic support. We report 2 cases in which extracorporeal membrane oxygenation was instituted emergently in the cardiac catheterization laboratory in patients with MI and cardiac arrest who underwent percutaneous coronary intervention and who were hemodynamically unstable despite inotropic agents and intraaortic balloon counterpulsation.     

Clinical significance of lactate in acute cardiac patients

Lactate, as a metabolite of easy and quick assessment, has been studied over time in critically ill patients in order to evaluate its prognostic ability. The present review is focused on the prognostic role of lactate levels in acute cardiac patients (that is with acute coronary syndrome, cardiogenic shock, cardiac arrest, non including post cardiac surgery patients). In patients with ST-elevation myocardial infarction treated with mechanical revascularization, hyperlactatemia identified a subset of patients at higher risk for early death and in-hospital complications, being strictly related mainly to hemodynamic derangement. The prognostic impact of hyperlactatemia on mortality has been documented in patients with cardiogenic shock and in those with cardiac arrest even if there is no cut-off value of lactate to be associated with worse outcome or to guide resuscitation or hemodynamic management. Therapeutic hypothermia seems to affect per se lactate values which have been shown to progressively decrease during hypothermia. The mechanism(s) accounting for lactate levels during hypothemia seem to be multiple ranging from the metabolic effects of reduced temperatures to the hemodynamic effects of hypothermia (i.e., reduced need of vasopressor agents). Serial lactate measurements over time, or lactate clearance, have been reported to be clinically more reliable than lactate absolute value also in acute cardiac patients. Despite differences in study design, timing of lactate measurements and type of acute cardiac conditions (i.e., cardiogenic shock, cardiac arrest, refractory cardiac arrest), available evidence strongly suggests that higher lactate levels can be observed on admission in non-survivors and that higher lactate clearance is associated with better outcome.     

No reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction

Percutaneous coronary intervention (PCI) is effective in opening the infarct related artery and restoring thrombolysis in myocardial infarction flow 3 (TIMI-flow 3) in large majority of ST-elevation myocardial infarction (STEMI). However there remain a small but significant proportion of patients, who continue to manifest diminished myocardial reperfusion despite successful opening of the obstructed epicardial artery. This phenomenon is called no-reflow. Clinically it manifests with recurrence of chest pain and dyspnea and may progress to cardiogenic shock, cardiac arrest, serious arrhythmias and acute heart failure. No reflow is regarded as independent predictor of death or recurrent myocardial infarction. No reflow is a multi-factorial phenomenon. However micro embolization of atherothrombotic debris during PCI remains the principal mechanism responsible for microvascular obstruction. This review summarizes the pathogenesis, diagnostic methods and the results of various recent randomized trials and studies on the prevention and management of no-reflow.     

Percutaneous ventricular assist device placement during active cardiopulmonary resuscitation for severe refractory cardiogenic shock after acute myocardial infarction

Cardiogenic shock after acute myocardial infarction is associated with a high mortality rate despite modern reperfusion methods and intra-aortic balloon pump support. For myocardial infarction patients in cardiogenic shock that is refractory to intra-aortic ballon pump counterpulsation and pressors (severe refractory cardiogenic shock), there are limited means to rapidly provide additional hemodynamic support. We present the case of a 49-year-old man who presented with an anterior wall acute myocardial infarction complicated by cardiogenic shock. After resuscitation and stabilization with intra-aortic balloon pump and pressor support, the patient underwent successful emergent percutaneous transluminal coronary angioplasty and stenting of the left anterior descending coronary artery. Forty-eight hours later, the patient again went into severe refractory cardiogenic shock; pulseless electrical activity arrest followed. Cardiopulmonary resuscitation was started, and the patient underwent urgent placement of a TandemHeart percutaneous ventricular assist device. The device enabled the reversal of terminal hemodynamic collapse during active cardiopulmonary resuscitation, subsequent stabilization of the patient, and discharge of the patient from the hospital after device removal. In this patient, the percutaneous ventricular assist device was successful in the treatment of severe refractory cardiogenic shock after acute myocardial infarction.     

The Role of Impella for Hemodynamic Support in Patients With Aortic Stenosis

Purpose of review

The goal of this review is to discuss the effects of Impella (Abiomed, Danvers, MA), to support in the hemodynamics of patients with severe aortic stenosis, and to explore the clinical scenarios in which the use of Impella may be beneficial in this setting.

Recent findings

The management of patients with severe aortic stenosis who go on to develop left ventricular failure and cardiogenic shock remains an important clinical challenge associated with increased morbidity and mortality.

Summary

Once considered a relative contraindication, the use of Impella in severe aortic stenosis has now been proven feasible and demonstrated promising results in selected high-risk patients. The use of Impella to provide hemodynamic support maybe considered in patients with aortic stenosis in cardiogenic shock or those with severe left ventricular dysfunction and CAD who require high-risk PCI and or balloon aortic valvuloplasty. Impella is also an attractive option in selected cases of hemodynamic collapse during TAVR.

     

主动脉内球囊反搏在急性心肌梗死合并心源性休克治疗中的应用

目的评价主动脉球囊反搏术(IABP)在急性心肌梗死(AMI)合并心源性休克治疗中的应用价值。方法选取AMI合并心源性休克患者65例,其中IABP组30例,在IABP支持下行急诊经皮冠状动脉介入治疗(PCI),对照组35例,单纯行急诊PCI治疗。结果IABP组患者在IABP支持下,30 min后血流动力学指标改善,2~8 h血流动力学稳定,均完成梗死相关血管再通,没有血管再闭塞事件发生,无术中死亡,院内死亡率40%;对照组患者院内死亡率74.3%,其中6例在术中死亡。结论IABP可明显改善AMI合并心源性休克患者的血流动力学指标,增加冠状动脉的灌注;IABP可提高急诊PCI的成功率,减少术后低心排综合征及血管再闭塞事件的发生,降低院内死亡率,明显改善了AMI合并心源性休克患者的预后。     

经皮机械循环支持设备治疗急性心肌梗死并发心源性休克研究进展

当前急诊经皮冠脉介入治疗技术日趋成熟规范，新型抗血小板药物广泛应用，主动脉球囊反搏泵（IABP）逐渐普及，但急性心肌梗死并发心源性休克患者死亡率仍居高不下。对此，包括Impella、TendemHeart和ECMO在内的经皮机械循环支持设备可通过提供较之IABP更强的血流动力学支持而有望改善心源性休克患者预后。尽管现有临床证据较少，仍不足以充分证明应用经皮机械循环支持设备救治的临床获益，同时应用后血管和全身并发症不容忽视，但随着技术的进步和临床应用经验的日益增加，经皮机械循环支持设备有望成为心梗并发心源性休克患者成功救治的关键所在。     

Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock

BackgroundTo investigate the feasibility and outcomes of Impella 2.5 support in patients with severe aortic valve stenosis (AS) and cardiogenic shock (CS), who underwent emergency percutaneous balloon aortic valvuloplasty (BAV) with or without percutaneous coronary intervention (PCI).Methods and resultsWe retrospectively analyzed a consecutive series of patients with severe AS and CS who underwent Impella 2.5 support following emergency BAV with or without subsequent PCI. Outcome data included 30-day outcomes, periprocedural as well as throughout the circulatory support period complications. Eight patients with severe AS and CS were identified. Impella 2.5 implantation was successful following emergency BAV in all patients attempted. Additional PCI was performed in four patients. No periprocedural deaths or periprocedural neurologic events occurred. Mean procedure time was 125.9 min (range 64–210 min). Mortality at 30 days was 50%.ConclusionsImpella 2.5 can be used as hemodynamic support in patients with severe AS and CS following emergency percutaneous BAV and may help to improve tolerability of PCI in these high-risk patients.     

直接经皮冠脉介入治疗在抢救急性心肌梗死合并心源性休克中的应用

目的探讨急性心肌梗死合并心源性休克的抢救方法。方法用急诊直接经皮冠脉介入治疗(PCI)治疗意大利波洛尼亚大学附属医院2001—2002年收治的15例急性心肌梗死合并心源性休克患者。结果15例患者中,共有13例抢救成功。结论急诊PCI是治疗急性心肌梗死合并心源性休克的有效方法。     

High-risk PCI in acute coronary syndromes with Impella LP 2.5 device support

Objectives

To evaluate feasibility, safety, efficacy as well as acute and short-term outcome of hemodynamically supported percutaneous coronary intervention (PCI) by a percutaneous, catheter-based left ventricular assist device (LVAD) (Impella LP 2.5, Abiomed Europe GmbH, Aachen, Germany) in a high-risk patient population with acute coronary syndrome.

Background

Although hemodynamic support by intraaortic balloon pump favorably affects myocardial oxygen supply and demand, it has modest effects on cardiac output, providing passive support only. In contrast, the Impella LP 2.5 microaxial pump, which is placed within the left ventricular outflow tract and actively ejects blood into the ascending aorta, might offer additional hemodynamic support and thereby procedural safety during PCI.

Methods

Thirty-eight consecutive high-risk patients (mean age, 69.7 ± 10.3 years, logistic EuroSCORE, 22.4 ± 14.9%) with unstable angina pectoris or non-ST-segment elevation myocardial infarction and severe three-vessel-disease were included in the study. Clinical and laboratory examinations were performed at baseline as well as at 6, 24 and 48 h after the procedure and 30 days after discharge.

Results

Device insertion and explantation was feasible in all patients without vascular complications and continuous hemodynamic stability was obtained during PCI. PCI was uneventfully performed in all but one patient for technical reasons. One non procedure-related death occurred 7 days after the intervention, accounting for a total 30-day mortality of 2.86%. Other major cardiac or cerebrovascular events did not occur.

Conclusions

LVAD support using a percutaneous microaxial flow pump is a promising and safe approach for high-risk PCI providing good short-term results.