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.

Download Full-text

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up

Medicina ◽

10.3390/medicina57080747 ◽

2021 ◽

Vol 57 (8) ◽

pp. 747

Author(s):

Rafal Berger ◽

Hasan Hamdoun ◽

Rodrigo Sandoval Boburg ◽

Medhat Radwan ◽

Metesh Acharya ◽

...

Keyword(s):

Quality Of Life ◽

Cardiogenic Shock ◽

Left Ventricular ◽

Ecmo Support ◽

Circulatory Support ◽

Significant Difference ◽

Va Ecmo ◽

Ecmo Therapy

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1–60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/−14) years and surgery was performed after a mean 12.1 (+/−8) days of VA-ECMO support. During follow-up of 46.9 (+/−25.5) months, there were 10 deaths after 20.4 (+/−12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/−21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/−5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.

Download Full-text

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Journal of Clinical Medicine ◽

10.3390/jcm10040759 ◽

2021 ◽

Vol 10 (4) ◽

pp. 759

Author(s):

Guillaume Schurtz ◽

Natacha Rousse ◽

Ouriel Saura ◽

Vincent Balmette ◽

Flavien Vincent ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Significant Difference ◽

Va Ecmo ◽

Unadjusted Analysis

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

Download Full-text

Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR

European Heart Journal ◽

10.1093/ehjci/ehaa946.1861 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

T Unoki ◽

Y Tamura ◽

T Nakayama ◽

M Kametani ◽

Y Minami ◽

...

Keyword(s):

Cardiac Arrest ◽

Hazard Analysis ◽

Left Ventricular ◽

Circulatory Support ◽

Rank Test ◽

Coronary Syndrome ◽

Shockable Rhythm ◽

Significant Difference ◽

Neurological Prognosis ◽

Va Ecmo

Abstract Background Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) is an effective tool for patients with refractory cardiac arrest (CA). Since VA-ECMO provides strong afterload, IABP is often used to increase left ventricular load. Recently, in Japan, the effectiveness of VA-ECMO in combination with IMPELLA, a forward flow mechanical circulatory support device (ECPELLA) is gaining attention. Purpose We investigated usefulness of ECPELLA in patients with refractory CA. Method We reviewed 133 patients that had E-CPR from January 2012 through January 2020 {mean age: 67±15 years, male 65%, Out of hospital Cardiac Arrest (OHCA) 35%, Acute coronary Syndrome (ACS) 54%}. We divided these patients into ECMO with IMPELLA (ECPELLA group), ECMO with IABP (IABP group) and ECMO alone (ECMO alone group). The primary endpoint is 30-day survival and good neurological prognosis defined as CPC (cerebral performance categories) 1 or 2. Result During the study period, of the 133 patients, there were 20 in the ECPELLA group, 78 in the IABP group, 35 in the ECMO alone group. There were no significant differences in age in all three groups. There were more males, shockable rhythm, OHCA and ACS in the ECPELLA and IABP groups compared to the ECMO alone group. But there was no significant difference between the ECPELLA and IABP groups. Compared with other groups, ECPELLA had the shortest time from cardiac arrest to ECMO placement. Regarding endpoints, the rate of 30-day survival and favorable neurological prognosis were higher in the ECPELLA group, followed by the IABP group and then the ECMO alone group. (ECPELLA: 55% vs. IABP: 23% vs. ECMO alone: 9%; P=0.0009, ECPELLA: 35% vs. IABP: 13% vs. ECMO alone: 9%; P=0.04) Next, Kaplan Meier analysis was performed to analyze 30-day all-cause mortality. The ECPELLA group had a significantly higher survival rate (P=0.01 by log-rank test). Multivariate cox proportional hazard analysis including the age, OHCA, shockable rhythm, ACS, Collapse-to-ECMO under 60 min revealed that the age (hazard ratio [HR], 1.28 (10 years increase), 95% confidence interval [CI], 1.08–1.53, P=0.004) and Collapse-to-ECMO under 60 min (HR, 0.37, 95% CI, 0.21–0.68, P=0.001) or ECPELLA (HR, 0.46, 95% CI, 0.20–0.694, P=0.03) were significantly associated with mortality. Conclusion ECPELLA used with E-CPR is an effective tool to improve mortality and neurologic status. Funding Acknowledgement Type of funding source: None

Download Full-text

Abstract 14670: A Meta-analysis of Survival Outcomes Between Two Uncommon Mechanical Circulatory Support Device Combinations

Circulation ◽

10.1161/circ.142.suppl_3.14670 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Kaushik Amancherla ◽

Jay Patel ◽

Tara Holder ◽

Jared O'Leary

Keyword(s):

Cardiogenic Shock ◽

Publication Bias ◽

Case Reports ◽

Meta Analysis ◽

Limb Ischemia ◽

Left Ventricular ◽

Small Sample ◽

Circulatory Support ◽

Significant Difference ◽

Va Ecmo

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella devices are being used in increasing frequency for cardiogenic shock. Left ventricular unloading strategies are often used in VA-ECMO. The combination of simultaneous left- and right-sided Impellas, colloquially called “BIPELLA”, also offers biventricular support. There is a paucity of data regarding these combinations of platforms. We performed a systematic review of the literature to assess clinical outcomes in patients treated with ECPELLA and BIPELLA for cardiogenic shock. Methods: A systematic search of PubMed using the terms “ECMO”, “ECPELLA”, “BIPELLA”, and “Impella” was performed. Included studies evaluated mortality and complications associated with use of ECPELLA and/or BiPELLA. Reference lists of eligible studies helped identify additional publications meeting inclusion criteria. Case reports and conference abstracts were excluded. Heterogeneity among eligible studies was assessed using the I2 statistic. Publication bias was assessed using Egger’s regression and visual inspection of funnel plots. The primary outcome was in-hospital or 30-day mortality. Secondary outcomes assessed complications. Results: The results of publication bias assessment are provided in Figure 1A. Egger’s test was not significant (p = 0.56). A total of 139 patients underwent ECPELLA implantation and 20 underwent BIPELLA implantation. Mortality for the overall cohort was 51% with no significant difference between groups (p = 0.93) (Figure 1B). There was no significant difference between the groups with bleeding (p = 0.74), hemolysis (p = 0.34), and limb ischemia (p = 0.58). Conclusion: These data suggest no differences in short-term mortality and certain complications between ECPELLA and BIPELLA strategies. However, the available literature is sparse, with small sample sizes and suffers from a paucity of significant hemodynamic data. Further prospective data are needed.

Download Full-text

Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽

10.1177/02676591211033947 ◽

2021 ◽

pp. 026765912110339

Author(s):

Shek-yin Au ◽

Ka-man Fong ◽

Chun-Fung Sunny Tsang ◽

Ka-Chun Alan Chan ◽

Chi Yuen Wong ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Primary Outcome ◽

Left Ventricular ◽

Circulatory Support ◽

Queen Elizabeth Hospital ◽

Intra Aortic Balloon Pump ◽

Membrane Oxygenation ◽

Significant Difference ◽

Va Ecmo

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

Download Full-text

Outcomes of non–acute coronary syndrome patients discharged from the emergency department with troponin positivity

CJEM ◽

10.2310/8000.2013.130949 ◽

2014 ◽

Vol 16 (01) ◽

pp. 41-52 ◽

Cited By ~ 4

Author(s):

Nathan W. Brunner ◽

Frank X. Scheuermeyer ◽

Eric Grafstein ◽

Krishnan Ramanathan

Keyword(s):

Acute Coronary Syndrome ◽

Cardiac Troponin ◽

Primary Outcome ◽

Univariate Analysis ◽

Left Ventricular ◽

Inpatient Admission ◽

Do Not Resuscitate ◽

Troponin Elevation ◽

Coronary Syndrome ◽

Significant Difference

ABSTRACT Background: Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs)without inpatient admission is notwell known. Methods: Patients without a diagnosis of acute coronary syndrome discharged fromtwo EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-not-resuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year. Results: Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1–5.0, p < 0.001) and both of its components (p < 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3–3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2–3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6–2.9, p 5 0.5) after adjustment. Conclusions: A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.

Download Full-text

Abstract 13425: Comparison Between Impella 5.0 and External Corporeal Left Ventricular Assist Device as a Bridge to Decision in Patients With Cardiogenic Shock

Circulation ◽

10.1161/circ.142.suppl_3.13425 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Toru Kondo ◽

Naoki Shibata ◽

shingo kazama ◽

Yuki Kimura ◽

Hideo Oishi ◽

...

Keyword(s):

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Assist Device ◽

Ventricular Assist ◽

Cardiac Recovery ◽

Left Ventricular Assist ◽

Bridge To Decision ◽

Va Ecmo

Background: In cardiogenic shock refractory to medical treatment, choosing and changing mechanical circulatory support to stabilize hemodynamics until cardiac recovery or next treatment is a strategic cornerstone for improving the outcome. We aimed to clarify the differences in treatment course and outcome between Impella 5.0 and extracorporeal left ventricular assist device (eLVAD) in patients with cardiogenic shock refractory to medical therapy or other mechanical circulatory support. Methods: We performed a retrospective medical record review of consecutive patients who were treated with Impella 5.0 or eLVAD as a bridge to decision (BTD) at our medical center from December 2011 to January 2020. Results: A total of 26 patients (median age 40 years, 16 males) were analyzed. Of seven patients managed with Impella 5.0, one patients used Impella CP and four patients used peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) before Impella 5.0 implantation. On the other hand, of 19 patients managed with eLVAD, 11 patients used VA-ECMO before eLVAD implantation. In patients managed with Impella 5.0, Impella 5.0 was removed successfully in two patients (29%) and four patients (71%) underwent the operation for durable LVAD. In patients managed with eLVAD, eLVAD was successfully removed in three patients (16%), nine patients (47%) required durable LVAD, and seven patients (37%) died during eLVAD management. The period between implantation of Impella 5.0 or eLVAD to durable LVAD surgery was significantly shorter with Impella 5.0 (58 [38 - 95] vs. 235 [126 - 318] days, p=0.001). During durable LVAD implantation, cardiopulmonary bypass time was significantly shorter and a significantly smaller amount of red blood cells transfusion was required with Impella 5.0 (149 [125 - 182] vs. 192 [170 - 250] minutes, p=0.042; 7.0 [5.0 - 9.5] vs. 15.0 [10.0- 2.0] units, p=0.019, respectively). There were 4 massive stroke events in eLVAD, but no massive stroke events in Impella 5.0. In Impella 5.0. Conclusions: Impella 5.0 facilitates smoother management as a BTD and reduces surgical invasiveness during durable LVAD implantation. Impella 5.0 would be a more effective option for success to cardiac recovery or next therapy than eLVAD.

Download Full-text

The safety of morphine use in acute coronary syndrome: a meta-analysis

Heart Asia ◽

10.1136/heartasia-2018-011142 ◽

2019 ◽

Vol 11 (1) ◽

pp. e011142 ◽

Cited By ~ 1

Author(s):

Rugheed Ghadban ◽

Tariq Enezate ◽

Joshua Payne ◽

Haytham Allaham ◽

Ahmad Halawa ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Major Bleeding ◽

Pain Control ◽

Controlled Trial ◽

Cochrane Central Register ◽

Minor Bleeding ◽

Coronary Syndrome ◽

Increased Risk ◽

Significant Difference ◽

All Cause Mortality

BackgroundMorphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction with and reduced efficacy of antiplatelet agents.ObjectiveThis study aims to systematically review the safety of morphine use in ACS.MethodsMEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were queried from inception through April 2018. Studies comparing morphine to nonmorphine use in ACS were included. Study endpoints included: in-hospital myocardial infarction (MI), all-cause mortality, stroke, major bleeding, minor bleeding and dyspnoea.ResultsA total of 64 323 patients with ACS were included from eight studies, seven of which were observational studies and one was a randomised controlled trial. The use of morphine was associated with increased risk of in-hospital recurrent MI (OR 1.30, 95% CI 1.18 to 1.43, p < 0.00001). There was, however, no significant difference in terms of all-cause mortality (OR 0.87, 95% CI 0.62 to 1.22, p = 0.44), stroke (OR 0.81, 95% CI 0.39 to 1.66, p = 0.57), major bleeding (OR 0.49, 95% CI 0.24 to 1.00, p = 0.05), minor bleeding (OR 0.98, 95% CI 0.41 to 2.34, p = 0.97), or dyspnoea (OR 0.55, 95% CI 0.16 to 1.83, p = 0.33).ConclusionThe use of morphine for pain control in ACS was associated with an increased risk of in-hospital recurrent MI. Randomised clinical trials are needed to further investigate the safety of morphine in ACS.

Download Full-text

Cardiogenic shock in patients with acute coronary syndromes

10.1093/med/9780199687039.003.0049 ◽

2015 ◽

Author(s):

Holger Thiele ◽

Uwe Zeymer

Keyword(s):

Intensive Care ◽

Cardiogenic Shock ◽

Acute Coronary Syndromes ◽

Artery Bypass ◽

Left Ventricular ◽

Circulatory Support ◽

Intensive Care Treatment ◽

Post Discharge ◽

Coronary Syndrome ◽

Coronary Syndromes

Cardiogenic shock complicating an acute coronary syndrome is observed in up to 10% of patients and is associated with high mortality still approaching 50%. The extent of ischaemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis of the cardiogenic shock patient. Careful risk assessment for each patient, based on clinical criteria, is mandatory, to decide appropriately regarding revascularization by primary percutaneous coronary intervention or coronary artery bypass grafting, drug treatment by inotropes and vasopressors, mechanical left ventricular support, additional intensive care treatment, triage among alternative hospital care levels, and allocation of clinical resources. This chapter will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of cardiogenic shock complicating acute coronary syndromes, including mechanical complications and shock from right heart failure. There will be a major focus on potential therapeutic issues from an interventional cardiologist’s and an intensive care physician’s perspective on the advancement of new therapeutical arsenals, both mechanical percutaneous circulatory support and pharmacological support. Since studying the cardiogenic shock population in randomized trials remains challenging, this chapter will also touch upon the specific challenges encountered in previous clinical trials and the implications for future perspectives in cardiogenic shock.

Download Full-text