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

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

Treatment of Cardiogenic Shock and Refractory Ventricular Fibrillation: Pulling Out All the Stops

“…14 If LV distension is detected, there are several ways of reducing afterload, including placement of an Impella device (so-called ECPELLA). 15 Fortunately, in our patient, the pulmonary artery diastolic pressure consistently remained < 22 mm Hg.…”

Utility of Left Ventricular Decompression in Veno-Arterial ECMO

“…A retrospective cohort study of matching 58 ECPella and 58 VA-ECMO patients in refractory CS observed that during the first 72 hours following initiation of VA-ECMO, the ECpella group had significantly higher mechanical circulatory flow support and had reduced catecholinergic pharmacologic support compared to the VA-ECMO alone group. Furthermore, the 30-day and 1-year survival rates were also noted to be significantly higher in the ECPella group [25].…”