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Simultaneous Venoarterial Extracorporeal Membrane Oxygenation and Percutaneous Left Ventricular Decompression Therapy with Impella Is Associated with Improved Outcomes in Refractory Cardiogenic Shock

Patel, Sandeep M.*; Lipinski, Jerry; Al-Kindi, Sadeer G.; Patel, Toral§; Saric, Petar§; Li, Jun; Nadeem, Fahd; Ladas, Thomas§; Alaiti, Amer; Phillips, Ann; Medalion, Benjamin; Deo, Salil; Elgudin, Yakov; Costa, Marco A.; Osman, Mohammed Najeeb; Attizzani, Guilherme F.; Oliveira, Guilherme H.; Sareyyupoglu, Basar; Bezerra, Hiram G.

doi: 10.1097/MAT.0000000000000767
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Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for refractory cardiogenic shock; however, it is associated with increased left ventricular afterload. Outcomes associated with the combination of a percutaneous left ventricular assist device (Impella) and VA-ECMO remains largely unknown. We retrospectively reviewed patients treated for refractory cardiogenic shock with VA-ECMO (2014–2016). The primary outcome was all-cause mortality within 30 days of VA-ECMO implantation. Secondary outcomes included duration of support, stroke, major bleeding, hemolysis, inotropic score, and cardiac recovery. Outcomes were compared between the VA-ECMO cohort and VA-ECMO + Impella (ECPELLA cohort). Sixty-six patients were identified: 36 VA-ECMO and 30 ECPELLA. Fifty-eight percent of VA-ECMO patients (n = 21) had surgical venting, as compared to 100% of the ECPELLA cohort (n = 30) which had Impella (±surgical vent). Both cohorts demonstrated relatively similar baseline characteristics except for higher incidence of ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) in the ECPELLA cohort. Thirty-day all-cause mortality was significantly lower in the ECPELLA cohort (57% vs. 78%; hazard ratio [HR] 0.51 [0.28–0.94], log rank p = 0.02), and this difference remained intact after correcting for STEMI and PCI. No difference between secondary outcomes was observed, except for the inotrope score which was greater in VA-ECMO group by day 2 (11 vs. 0; p = 0.001). In the largest US-based retrospective study, the addition of Impella to VA-ECMO for patients with refractory cardiogenic shock was associated with lower all-cause 30 day mortality, lower inotrope use, and comparable safety profiles as compared with VA-ECMO alone.

From the *Interventional Cardiology, The Heart Specialists of St. Rita’s, St. Rita’s Medical Center, Mercy Health, Lima, Ohio

School of Medicine, Case Western Reserve University, Cleveland, Ohio

Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio

§Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Submitted for consideration August 2017; accepted for publication in revised form October 2017.

Disclosures: Bezerra is a consultant for Abiomed.

Basar Sareyyupoglu and Hiram G. Bezerra contributed equally to the senior authorship of this article.

Correspondence: Hiram G. Bezerra, Department of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. Email: hiram.bezerra@uhhospitals.org; and Basar Sareyyupoglu, Department of Cardiothoracic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. Email: basar.sareyyupoglu@uhhospitals.org.

Copyright © 2019 by the American Society for Artificial Internal Organs