High flow from Impella 5.5 with partial veno‐arterial extracorporeal membrane oxygenation support: Case series

Abstract

Optimal flow balance between Impella 5.5 and veno-arterial extracorporeal membrane oxygenation (ECMO) support in the setting of EC-PELLA (ECMO+Impella) is unknown. Outcomes of high Impella 5.5 flow in the setting of EC-PELLA support were reviewed (N = 7). EC-PELLA was successfully explanted in 6 patients (bridge-to-transplant, N = 1; bridge-to-recovery, N = 5). The median duration of EC-PELLA support in explanted patients was 6 days. Survival at discharge was 71.4% (5 patients). In terms of device-related events, either VA-ECMO or Impellarelated complications were not experienced. The median performance level of Impella 5.5 was P5 at the time of starting EC-PELLA support and then increased with time up to the median of P8 with increment of the Impella flow, and index (L/min/m 2 ). The percentage of Impella flow per total EC-PELLA flow reached 50% after 48 h of support. The vasoactive-inotropic score and serum lactate level improved after institution of EC-PELLA support as well as the pulmonary artery pressures and central venous pressure. In conclusion, a high pump flow from Impella 5.5 with partial VA-ECMO support in the setting of EC-PELLA provided great support with favorable survival and device-related complications rate.

Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference?

“…In summary, we think that our data allow important insights concerning the most optimal therapy control during biventricular support. Furthermore, our results also agree with those of Ohira et al, who also described an increase of CO when increasing Impella support in the case of biventricular MCS [ 9 ].…”

“…Over the past decade, we learned that, in CS patients treated with VA-ECMO, the implementation of an additional left ventricular unloading with Impella (so-called ECMELLA) is associated with a lower mortality rate in comparison to VA-ECMO alone [ 5 – 7 ]. Thereby, Impella not only increases cardiac index (CI) and cardiac output (CO) but also reduces systemic vascular resistance (SVR), and serum lactate as indicators for improved tissue and organ perfusion [ 8 , 9 ].…”

Evolution of concomitant use of veno‐arterial extracorporeal membrane oxygenation support with Impella in cardiogenic shock: From percutaneous femoral Impella to axillary Impella 5.5

“…Our VA-ECMO technique with concomitant use of Impella in an ECPELLA configuration and its management has been previously reported 5,6 Impella 5.5 was exclusively implanted through the axillary artery with an 8 mm or 10 mm Dacron graft. Systemic intravenous heparin was used to achieve the activated partial thromboplastin time of 45-65 s and purge heparin solution was administrated as per manufacturer instructions.…”

Escalation from intra-aortic balloon pump to axillary impella 5.5 support: Staged removal of the femoral access

“…When this happens, two potential issues may arise: first is achieving hemostasis of the femoral artery where the IABP is placed; and second is the possibility of further escalation of support after insertion of Imeplla 5.5 such as addition of peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support, known as EC-PELLA (VA-ECMO + Impella). 3,4 In order to achieve hemostasis of the IABP site in the operative room (OR), manual compression or device closure may pose a risk of bleeding due to heparinization during Impella 5.5 placement and abnormal coagulation system from heart failure, 5,6 especially in patients with large body habitus and/ or deep femoral vessels. Furthermore, an attempt of hemostasis in the OR may be associated with longer procedure time.…”

“…When this happens, two potential issues may arise: first is achieving hemostasis of the femoral artery where the IABP is placed; and second is the possibility of further escalation of support after insertion of Imeplla 5.5 such as addition of peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support, known as EC-PELLA (VA-ECMO + Impella). 3,4…”