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In refractory cardiogenic shock, temporary mechanical circulatory support (tMCS) can be used to improve tissue perfusion and oxygen delivery.
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tMCS could serve as a bridge-to-recovery or as a bridge-to-decision (improving current organ function and assessing contraindications for heart transplantation or permanent left ventricular assist device [LVAD] implantation).
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In recent years, venoarterial extracorporeal membrane oxygenation has been used in combination with Impella (ECPELLA) in patients with severe shock.
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In our cohort, patients supported with ECPELLA had a 30-day mortality of 20%, which is lower than reported in the literature; 50% underwent LVAD implantation.
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ECPELLA support is associated with important complications (bleeding, haemolysis and vascular complications).
Background
Methods
Study population
Mechanical support
Outcomes
Statistical analysis
Results
Baseline characteristics
Baseline characteristics | |
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Age (years, mean ± SD) | 51.3 (9.4) |
Gender (male, %) | 14 (70) |
BMI (kg/m2, mean ± SD) | 24.7 (3.6) |
Race (Caucasian, %) | 15 (75) |
Hypertension (n, %) | 5 (25) |
Diabetes mellitus (n, %) | 3 (15) |
Peripheral artery disease (n, %) | 0 (0) |
Ischaemic CVA (n, %) | 1 (5) |
Myocardial infarction (n, %) | 3 (15) |
Percutaneous revascularisation (n, %) | 3 (15) |
CABG (n, %) | 0 (0) |
Smoking (n, %) | |
– Never smoked | 13 (65) |
– Previous smoker | 3 (15) |
– Current smoker | 3 (15) |
– Unknown | 1 (5) |
Atrial fibrillation (n, %) | 3 (15) |
Chronic kidney disease (n, %) | 1 (5) |
ICD (n, %) | 5 (25) |
Pacemaker (n, %) | 1 (5) |
Number of platelet aggregation inhibitors (n, %) | |
– 0 | 11 (55) |
– 1 | 2 (10) |
– 2 | 7 (35) |
Clinical profile of cardiogenic shock
Clinical profile of cardiogenic shock | |
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Heart rate (beats/min, mean ± SD) | 109 (26) |
Systolic blood pressure (mm Hg, mean ± SD) | 86 (13) |
Diastolic blood pressure (mm Hg, mean ± SD) | 54 (13) |
Rhythm | |
– Sinus rhythm (n, %) | 16 (80) |
– Atrial fibrillation/atrial flutter (n, %) | 4 (20) |
Creatinine (µmol/l, mean ± SD) | 142 (43) |
Sodium (mmol/l, mean ± SD) | 138 (5) |
Potassium (mmol/l, mean ± SD) | 4.2 (0.7) |
Urea (mmol/l, mean ± SD) | 15.7 (8.5) |
Haemoglobin (mmol/l, mean ± SD) | 8.2 (1.7) |
Leucocytes (× 109/l, mean ± SD) | 20.8 (9.6) |
Lactate (mmol/l, median/IQR) | 3.0 (2.5–4.3) |
Bilirubin (µmol/l, median/IQR) | 13 (11–20) |
CPR (mg/dl, median/IQR) | 65 (11–149) |
Thrombocytes (× 109/l, median/IQR) | 215 (146–270) |
Inotropes use (n, %) | 14 (70) |
Vasopressor use (n, %) | 16 (80) |
Mechanical ventilation (n, %) | 14 (70) |
Previous IABP (n, %) | 3 (15) |
CPR before ECPELLA (n, %) | 5 (25) |
Cause of cardiogenic shock (n, %) | |
– Myocarditis | 3 (15) |
– Acute coronary syndrome | 8 (40) |
– Acute failure with known cardiomyopathy | 6 (30) |
– Post-thoracotomy | 2 (10) |
– Pheochromocytoma | 1 (5) |
SCAI shock classification (n, %) | |
– Stage C | 1 (5) |
– Stage D | 12 (60) |
– Stage E | 7 (35) |
ECPELLA indication (n, %) | |
– Severe LV dysfunction/shock | 14 (70) |
– LV unloading | 5 (25) |
– Shock and high-risk PCI | 1 (5) |
Timing of ECPELLA support (n, %) | |
– Simultaneous insertion | 12 (60) |
– Impella first ‘early’ | 2 (5) |
– Impella first ‘late’ | 1 (5) |
– VA-ECMO first ‘late’ | 5 (25) |
Access site, left femoral artery (n, %) | 12 (60) |
Duration of ECPELLA support (h) | 164 (98–210) |
Clinical outcomes
Clinical outcomes, safety and complications | |
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Clinical outcomes | |
LVAD implantation (n, %) | 10 (50) |
Heart transplantation (n, %) | 0 (0) |
30-day cardiac recovery (n, %) | 6 (30) |
30-day mortality (n, %) | 4 (20) |
90-day mortality (n, %) | 6 (33) |
Safety/complications | |
(i)CVA (n, %) | 0 (0) |
Vascular (n, %) | 6 (30) |
– Bleeding, requiring intervention | 3 (15) |
– Ischaemic, requiring intervention | 3 (15) |
– Dissection | 1 (5) |
Haemolysis (n, %) | 5 (25) |
Major bleeding (n, %) | 8 (40) |
– Vascular access site | 2 (10) |
– Gastrointestinal | 2 (10) |
– Haemothorax | 2 (10) |
– Pulmonary | 1 (5) |
Kidney failure requiring replacement therapy (n, %) | 10 (50) |
Impella failure requiring extraction (n, %) | 3 (15) |
Mitral valve replacement due to papillary rupture | 1 (5) |