Early Impella Support in Postcardiac Arrest Cardiogenic Shock Complicating Acute Myocardial Infarction Improves Short- and Long-Term Survival*

Abstract

OBJECTIVES: Early mechanical circulatory support with Impella may improve survival outcomes in the setting of postcardiac arrest cardiogenic shock after out-of-hospital cardiac arrest complicating acute myocardial infarction. However, the optimal timing to initiate mechanical circulatory support in this particular setting remains unclear. Therefore, we aimed to compare survival outcomes of patients supported with Impella 2.5 before percutaneous coronary intervention (pre-PCI) with those supported after percutaneous coronary intervention (post-PCI). DESIGN: Retrospective single-center study between September 2014 and December 2019 admitted to the Cardiac Arrest Center in Marburg, Germany. PATIENTS: Out of 2,105 patients resuscitated from out-of-hospital cardiac arrest due to acute myocardial infarction with postcardiac arrest cardiogenic shock between September 2014 and December 2019 and admitted to our regional cardiac arrest center, 81 consecutive patients receiving Impella 2.5 during admission coronary angiogram were identified. OUTCOMES/MEASUREMENTS: Survival outcomes were compared between those with Impella support pre-PCI to those with support post-PCI. MAIN RESULTS: A total of 81 consecutive patients with infarct-related postcardiac arrest shock supported with Impella 2.5 during admission coronary angiogram were included. All patients were in profound cardiogenic shock requiring catecholamines at admission. Overall survival to discharge and at 6 months was 40.7% and 38.3%, respectively. Patients in the pre-PCI group had a higher survival to discharge and at 6 months as compared to patients of the post-PCI group (54.3% vs 30.4%; p = 0.04 and 51.4% vs 28.2%; p = 0.04, respectively). Furthermore, the patients in the early support group demonstrated a greater functional recovery of the left ventricle and a better restoration of the end-organ function when Impella support was initiated prior to percutaneous coronary intervention. CONCLUSIONS: Our results suggest that the early initiation of mechanical circulatory support with Impella 2.5 prior to percutaneous coronary intervention is associated with improved hospital and 6-month survival in patients with postcardiac arrest cardiogenic shock complicating acute myocardial infarction.

Improved Survival Through Early Versus Late Impella Support for Myocardial Infarction–Related Shock? Mind Your Step!

“…Although doctors typically do their utmost to reserve potentially harmful interventions for those who would benefit most and refrain from such interventions in patients in whom potential benefit would be outweighed by risk, the assumption of exchangeability would not hold (3). No undertaking for adjustment of potential confounding was reported in the current study by Chatzis et al (1). As one of the possible confounding factors, the observed difference in average age between both groups (early group: 66.0 [sd: 13.6], delayed group: 70.2 [11.2]) is of interest.…”

“…The authors reply: W e are most grateful to Meuwese et al (1) for their interest in our study (2) as well as their observations and thoughtful critique. In the following text, we address all remarks made by Meuwese et al (1) point by point.…”

“…To the Editor: W ith great interest, we read a study by Chatzis et al (1) published in a recent issue of Critical Care Medicine reporting improved survival after receiving an Impella before versus after percutaneous coronary intervention (PCI) for cardiogenic shock after myocardial infarction. The study by Chatzis et al (1) materializes the concept of left ventricular (LV) unloading prior to PCI to reduce reperfusion injury and eventually infarct size. Despite its topicality, we believe that present findings could have been compromised by some important methodological issues.…”

Device fracture as a potential complication of a left ventricular microaxial pump catheter: a case report

“…By providing haemodynamic support in critically ill patients, LVADs may improve the overall outcome. 1 , 3 However, their application is not without complications. Among them, groin bleeding is quite common after device placement or removal.…”

“…The use of percutaneous left ventricular assist devices (LVADs), such as an Impella pump catheter, has advanced substantially in the last few years due to the simple insertion procedure and smaller device size. 1 , 2 However, their use is still associated with some risks and complications. Here, we report a device fracture as a rare complication that occurred during the device extraction a few days after the initial insertion.…”