Impella for the management of ventricular septal defect complicating acute myocardial infarction: insights from an European multicenter retrospective analysis. The VSD-IMPELLA study

Abstract

Funding Acknowledgements Type of funding sources: None. Backgroud Ventricular septal defect (VSD), is a rare but fatal complication of myocardial infarction (MI) associated with high early mortality. Temporary mechanical circulatory support (t-MCS) of any type can be used to stabilize the patient as a bridge to surgical or percutaneous closure, or to heart transplantation or long-term ventricular assist device, but with a low level of evidence. The Impella® device is a trans-valvular aortic axial pump inserted surgically or percutaneously which pumps blood directly from the left ventricle into above the aortic valve. Its hemodynamic effects seem interesting, explaining its use by certain expert centers in this context, but the data in this indication are rare in the literature. Method It was an European retrospective multicentre registry of patients hospitalized for ischemic VSD managed with an Impella® (2.5, CP or 5.0) over the past 10 years (2010 to 2021). The primary endpoint was in-hospital mortality. The secondary endpoints were the monitoring of clinical, hemodynamic and biological data at 24 hours, the medications and organ supports used during hospitalization, intra-hospital complications and mortality at 6 months and 1 year. Results On 20 centers contacted, 17 responded (85%). A total of 28 patients managed with an Impella® device for an ischemic VSD in 7 European center were included (41% of respondents). All patients included were in cardiogenic shock (100%, n=28) with multiple organ failure (SAPSII 41 [IQR 53-27], Euroscore 57 [IQR 75-23] and arterial lactate 6 +/-5 mmol). The majority of patients required inotropic and vasopressor support (dobutamine 55% and norepinephrine 96%). In-hospital and 1-year mortalities were 75%. Surgical closure of the VSD was performed in 36% of patients, percutaneous closure in 21% and medical treatment alone for 43, with in-hospital mortality of 30, 92 and 100% respectively. Hospital mortality also seemed to be associated with the type of t-MCS used (71% for Impella alone, 67% for Impella® with IABP combination and 78% for Impella® with ECLS combination). Survivors were more likely to have benefited from CABG revascularization (p < 0.011). Conclusion Despite the potential hemodynamic advantages, the use of Impella® in patients with ischemic VSD is associated with high mortality which may be partly related to its exclusive use in the most severe cardiogenic shock patients, to associated therapies in particular the type of closure of the VSD, or the complications of the device itself.

Impella Support for Postmyocardial Infarction Ventricular Septal Rupture

“…It was with great interest that we read the article published by Delmas et al ., 1 which is a European multicenter survey on the use of Impella devices as a bridge to surgical repair, bridge to percutaneous closure, or bridge to recovery/no intervention. This study included 28 patients with postmyocardial infarction ventricular septal ruptures (post-MI VSRs), who were all in cardiogenic shock upon presentation.…”

“…Veno-arterial (VA) ECMO can increase left ventricular (LV) afterload, worsen left-to-right shunting, and is usually avoided as a sole means of MCS in post-MI VSRs. Nonetheless, few case series, including this study by Delmas et al ., 1 have demonstrated successful LV unloading and hemodynamic support with Impella, for patients with post-MI VSRs, before surgical repair. 7,8 The use of Impella devices for VSRs is relatively contraindicated, as it can theoretically reverse the shunt causing hypoxia and can also dislodge the fragile infarcted septal tissue causing distal embolization, including stroke.…”

“…Despite our endorsement for using Impella devices in patients with post-MI VSRs, we have some comments on this article by Delmas et al . 1 The inclusion of the Impella 2.5 and Impella 5 in the study, is clinically irrelevant, because both devices are rarely, if ever, used and have been largely replaced by their successors, the Impella CP and the Impella 5.5, respectively, which are both far superior. They report that severe access site hemorrhage was their most common complication (50%), followed by hemolysis (12%).…”