Left Impella®-device as bridge from cardiogenic shock with acute, severe mitral regurgitation to MitraClip®-procedure: a new option for critically ill patients

Abstract

Aims Patients presenting with cardiogenic shock (CS) related to acute, severe mitral regurgitation (MR) are often considered too ill for immediate surgical intervention. Therefore, other less invasive techniques for haemodynamic stabilization should be explored. The purpose of this exploratory study was to investigate the feasibility and outcomes in patients with CS due to severe MR by using a novel approach combining haemodynamic stabilization with left Impella-support plus MR-reduction using MitraClip®. Methods and results We analysed whether a combined left Impella®/MitraClip®-procedure in a rare population of CS-patients with acute MR requiring mechanical ventilation is a feasible strategy to recovery in patients who had been declined cardiac surgery. Six INTERMACS-1 CS-patients with acute MR were studied at two tertiary cardiac intensive care units. The mean EURO-II score was 39 ± 19% and age 66.8 ± 4.9 years. All patients had an initial pulmonary capillary wedge pressure >20 mmHg and pulmonary oedema necessitating invasive ventilation. Cardiac output was severely impaired (left ventricular outflow tract velocity time index 9.8 ± 1.8 cm), requiring mechanical circulatory support (MCS) (Impella®-CP; mean flow 2.9 ± 1.8 L per minute; mean support 9.7 ± 6.0 days). Despite MCS-guided unloading, weaning from ventilation failed due to persisting pulmonary oedema necessitating MR-reduction. In all cases, the severe MR was reduced to mild using percutaneous MitraClip®-procedure, followed by successful weaning from invasive ventilation. Survival to discharge was 86%, with all surviving and rare readmission for heart failure at 6 months. Conclusions A combined Impella®/MitraClip®-strategy appears a novel, feasible alternative for weaning CS-patients presenting with acute, severe MR. Upfront Impella®-stabilization facilitates safe bridging to Mitraclip®-procedure and the staged approach facilitates successful weaning from ventilatory support.

Effect of Impella 5.5 on Preexisting Functional Mitral Regurgitation in Patients with Heart Failure–Related Cardiogenic Shock

“…Baseline hemodynamics in patients with trace/mild FMR were not significantly different from patients with moderate and moderate-tosevere/severe FMR. At 24 hours post-Impella implant, there was a significant decrease in CVP (12 [8-14] to 9 [7][8][9][10][11], p ¼ 0.012), a significant decrease in pulmonary artery diastolic pressure (PADP; 25 [19][20][21][22][23][24][25][26][27] to 18 [14-21], p ¼ 0.002) and pulmonary capillary wedge pressure (22 [16][17][18][19][20][21][22][23][24][25][26] to 17 [10][11][12][13][14][15][16][17][18][19][20], p ¼ 0.008), a significant drop in systemic vascular resistance (1541 [1225-1914] to 960 [864-1183], p 0.001), a significant decrease in serum lactate levels (1.9 [1.2-2.7] to 1.3 [1-1.7], p ¼ 0.046), and a significant decrease in vasoactive-inotrope score (VIS; 12 [7][8][9][10][11][12][13][14][15][16][17][18]…”

“…This study also found that neither baseline nor residual MR affected survival at 24 months post-LVAD implant. 13 The Impella 5.5 can provide flows comparable to durable LVADs, but only small case series have examined the use of Impella in the setting of CS with concomitant severe MR. 9,10 In our small, retrospective cohort, we make 3 important observations: (1) the Impella 5.5 did not appear to acutely (within 24 hours) ameliorate moderate or greater FMR; (2) Impella 5.5 did provide significant left ventricular unloading as evidenced by a reduction in intracardiac filling pressures and lactate clearance as well as a significant decrease in systemic vascular resistance and vasoactive-inotrope score (Table 1); and (3) a significant proportion of patients in our cohort (42%) experienced NHR on Impella 5.5 support, regardless of baseline/residual FMR severity (Figure 1). These observations were made across the entire cohort, regardless of baseline severity of FMR.…”

Hemodynamic assessment and risk classification for successful weaning of Impella in patients with cardiogenic shock

“…We speculated that significant MR before Impella weaning was related to outcomes after Impella weaning. These patients could be considered for additional interventions, such as surgical or edge‐to‐edge mitral valve repair, prior to Impella weaning 24–26 . Our study included three cases that supported this approach.…”

“…Of four patients who were weaned Impella because of complications, three patients with intracranial hemorrhage had PAWP 17 mm Hg [IQR 8-20], MPAP 25 mm Hg [23][24][25][26], and CPO 0.61 Watts [0.55-0.65], one patient with limb ischemia had PAWP 15 mm Hg, MPAP 23 mm Hg, and CPO 0.61 Watts before weaning. Four non-survival patients with bleeding events as causes of deaths after Impella weaning had PAWP 18 mm Hg [10][11][12][13][14][15][16][17][18][19][20][21], MPAP 25 mm Hg [23][24][25][26], and CPO 0.58 Watts [0.43-0.64] before weaning.…”

Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology

“…Extremely rare applications, such as Impella-facilitated edge-to-edge mitral valve repair, are beyond the scope of this review. 67 A final section discusses Impella-associated complications.…”