Left Ventricular Unloading by Impella Device during Extracorporeal Life Support

Objectives: Implanting venoarterial extracorporeal membrane oxygenation (VA-ECMO) in cardiogenic shock allows patient bridging to decision. Left ventricular (LV) unloading is needed in patients with LV akinesia, developing pulmonary edema or LV thrombosis. An Impella (IP) is used for unloading the left ventricle in inotrope refractory akinesia. In patients treated with the combination of VA-ECMO and IP, we sought to determine clinical variables associated to 30-day mortality.

Methods: A total of 75 patients underwent concomitant treatment with VA-ECMO and IP at our center. VA-ECMO was implanted via the groin. IP was placed via the femoral (n = 70) or subclavian artery (n = 5). We present result of all patients surviving a minimum of 24 hours on VA-ECMO/IP support. Another nine patients died within 24 hours after implantation and remained excluded.

Results: Cardiogenic shock resulted from AMI in 24 patients (32%), postcardiotomy syndrome in 13 (17%), CHF in 25 (33%), and miscellaneous causes in 13 (17%). A 30-day mortality was 44% (n = 33) and median survival 27.6 ± 9.4 months. Causes of death consisted of multiple organ failure (49%), neurologic injury (28%), refractory myocardial insufficiency (19%), and respiratory failure (4%). Mean VA-ECMO/IP support time was 6.7 (1–21) days. Twenty-six patients (35%) recovered myocardial function and 23 patients (31%) were bridged to a long-term VAD. Two patients (3%) underwent HTX. Age, body mass index, renal failure, increased serum lactate, and LV stasis were independent predictors for death (p < 0.05, each).

Conclusion: Concomitant VA-ECMO/IP support achieved LV unloading in all patients allowing bridging to recovery or definite therapy in a relevant patient proportion. Hence, it might improve outcome in presence of LV congestion on peripheral VA-ECMO.