Can we have a rationalized selection of intra-aortic balloon pump, Impella, and extracorporeal membrane oxygenation in the catheterization laboratory?

Abstract

Cardiac assistance represents an emerging issue in cardiovascular medicine. The evolution of invasive cardiology techniques is making the catheterization laboratory one of the main hospital sites where implantation of percutaneous ventricular assistance devices (PVADs) is discussed and performed. Among available PVADs, intra-aortic balloon pump (IABP), Impella, and extracorporeal membrane oxygenation (ECMO) are the most popular and offer completely different levels and ways to assist critical patients. The main settings calling for PVAD consideration in the catheterization laboratory are clinically indicated high-risk patients (CHIP) undergoing percutaneous coronary intervention (PCI) and patients with cardiogenic shock or refractory cardiac arrest. In CHIP, PVAD serves the purpose of preventing hemodynamic collapse during PCI. This may also allow more extensive revascularizations and higher quality revascularization plans (imaging use, debulking, stent result optimization). IABP or Impella are more commonly selected whereas ECMO is seldom considered as a third option for highly selected patients. The “elective” nature of CHIP-PCI should allow careful procedure planning (peripheral artery disease assessment, access site selection and management) in order to minimize vascular/bleeding complications. Cardiogenic shock is still associated with high mortality rates, and PVAD theoretically offers further recovery chances. The lack of benefit observed with systematic IABP use is currently prompting consideration of the roles of Impella and ECMO. Prolonged assistance is often needed. Thus, team decisions and shared protocols for PVAD selection have to be promoted, taking into consideration available resources and operators’ skills. In this paper, we critically review the available data in the field and highlight the possible decision-making hubs that catheterization-laboratory teams may consider in order to rationalize PVAD selection.

Has the role of veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock following acute myocardial infarction been fully determined? A case report

“…Additionally, for the purpose of left ventricular unloading, a combination of Impella + ECMO or intra-aortic balloon pump (IABP) + ECMO has shown promising evidence. 9 Reports suggest that Impella’s role is comparable with VA ECMO in AMI-complicated CS, but accessibility remains an issue in developing countries like Vietnam. 10 Moreover, the ECLS-SHOCK study did not report the VIS—a highly relevant index for determining the need for VA ECMO and predicting patient outcomes.…”

Prophylactic Impella CP versus VA-ECMO in Patients Undergoing Complex High-Risk Indicated PCI

“…To prevent these hemodynamic unfavorable effects, VA-ECMO is in long-term support and generally used in combination with other devices for MCS such as Impella or IABP, but not for short-term support as in CHIP [ 19 , 20 ]. During VA-ECMO support, vasodilators might reduce afterload and LV end-diastolic pressure, while inotropes can increase contractility [ 21 ].…”

Post-Myocardial Infarction Ventricular Septal Defect

“…8 Although combination of Impella and ECMO might represent an interesting solution from a hemodynamic standpoint, the large bore sheaths required may increase vascular and bleeding complications affecting, in turn, short-term survival. 9 , 10 …”