Table 1.
Clinical details of patients with CS who received Impella∗ and VA-ECMO
| Age/Sex∗ | Clinical course | Cardiac arrest pre- MCS/SCAI stage | RV-D | In-hospital death (cause of death) | Other remarks | Retrospective shock-team recommendations on MCS decisions |
|---|---|---|---|---|---|---|
| Impella | ||||||
| 40M | STEMI post-thrombolytics, recurrent ventricular fibrillation, CS. Femoral access for angiography with no PCI performed. Impella CP was inserted. Onset of symptoms to catheterization laboratory arrival was 9 hours. Baseline lactate 5 mmol/L. | Yes SCAI stage C |
No | Yes (progressive shock) | Concerns regarding flow and position | VA-ECMO instead of Impella to facilitate PCI, especially given recurrent ventricular arrhythmia |
| 65M | Possible myocarditis, with no significant coronary artery disease. Femoral access for angiography followed by insertion of Impella CP. Baseline lactate 15 mmol/L. | Yes SCAI stage C |
Yes | Yes (progressive shock) | – | VA ECMO given RV dysfunction |
| 60F | NSTEMI , iatrogenic left main dissection during PCI resulting in CS followed by insertion of Impella CP. PCI was performed via radial approach. Baseline lactate was not available. | Yes SCAI stage D |
No | Yes (progressive shock) | Concerns regarding flow and position | VA-ECMO for CS in cases of catastrophic PCI complications |
| 70F | Late anterior STEMI with occluded LAD with VSD, Impella CP was inserted. Femoral access for angiography. No thrombolytic was given. Onset of symptoms to catheterization laboratory arrival was ∼24 hours. Baseline lactate was not available. |
No SCAI stage C |
Yes | Yes (progressive shock) | - | Pharmacologic support, given late presentation, lack of revascularization, and RV dysfunction |
| 35M | Anterior STEMI, thrombolysis followed by PCI to LAD. Impella was inserted and removed shortly thereafter after because of vascular complication. Further deterioration given pulmonary hemorrhage requiring VV-ECMO, which was decannulated later. PCI was performed via femoral access. Onset of symptoms to catheterization laboratory arrival was ∼4 hours. Baseline lactate of 5 |
Yes SCAI stage D |
No | Survived | Large right femoral artery pseudo-aneurysm | Medical management without MCS; Impella was a reasonable option |
| 55M | Anterior STEMI caused by stent thrombosis with CS managed with thrombolysis followed by rescue PCI followed by insertion of Impella CP. PCI was performed via femoral approach. First medical encounter to catheterization laboratory arrival was ∼48 hours. Baseline lactate 1 mmol/L. | Yes SCAI stage C |
No | Yes (progressive shock) | – | Impella was a reasonable initial choice, with upgrade to VA-ECMO upon deterioration |
| 65M | Severe chronic ischemic cardiomyopathy with acute decompensation. Femoral access for angiography. Impella CP was inserted. Baseline lactate of 8 mmol/L. | No SCAI stage C |
Yes | Yes (progressive shock) | Issues with Impella flow | Medical management without MCS |
| 75F | STEMI post-thrombolysis with VSD and CS followed by insertion of Impella 2.5, which was continued after VSD surgical repair. Femoral access for angiography. First medical contact to catheterization laboratory arrival was ∼26 hours. Baseline lactate of 8 mmol/L. | No SCAI stage D |
Yes | Yes (progressive shock) | Issue with Impella position | IABP, as Impella is contraindicated with VSD |
| 75F | STEMI post-thrombolysis with CS underwent PCI followed by IABP and Impella CP. Femoral access for angiography. First medical contact to catheterization laboratory arrival was ∼10 hours. Baseline lactate of 7 mmol/L. | No SCAI stage C |
No | Yes (progressive shock) | – | MCS decision was reasonable |
| 75F | STEMI presenting with VSD, and CS, followed by insertion of Impella CP. Patient's condition continued to deteriorate before surgical repair. First medical encounter to catheterization laboratory arrival was ∼24 hours. Baseline lactate 4 of mmol/L. | No SCAI stage D |
No | Yes (progressive shock) | – | IABP, as Impella is contraindicated with VSD |
| 60F | STEMI post-thrombolysis with ventricular fibrillation and CS underwent PCI followed by insertion of Impella CP. Femoral access for angiography. First medical encounter to catheterization laboratory arrival was ∼24 hours Lactate not available. | Yes SCAI stage C |
No | Yes (progressive shock) | Issue with position of Impella | VA-ECMO, given recurrent ventricular arrhythmia |
| 50M | Viral cardiomyopathy and rapid atrial fibrillation, severe LV dysfunction. Baseline lactate of 3 mmol/L. | No SCAI stage D |
No | Yes (cerebellar hemorrhage) | – | VA-ECMO and early transfer to regional transplant centre for advanced heart-failure therapy |
| 80F | Catheter-induced left main artery thrombosis or dissection resulting in CS underwent PCI followed by insertion of Impella CP. PCI was performed via femoral access. Baseline lactate was not available. |
Yes SCAI stage E |
No | Yes (circulatory failure and pulmonary hemorrhage) | Access-site bleeding | Supportive medical care with no MCS, given age and advanced stage of shock |
| 70F | STEMI underwent PCI and insertion of Impella CP, which was weaned in 72 hours. PCI was performed via radial access. First medical encounter to catheterization laboratory arrival was ∼7 hours. Baseline lactate 3 mmol/L | Yes SCAI stage C |
No | Survived | Massive transfusion related to groin-site bleeding | MCS decision here was reasonable |
| 70M | NSTEMI with recurrent chest pain. Impella CP inserted for stabilization. Weaned from Impella in 48 hours, followed by recurrent shock. Femoral access for angiography. Baseline lactate 5 mmol/L. | Yes SCAI stage C |
Yes | Yes Recurrent CS |
– | Right heart catheterization to help guide initial MCS choice and subsequent weaning |
| VA-ECMO | ||||||
| 55F | Left main NSTEMI with CS with profound hypoxemia despite maximum pressors and ventilation. PCI to left main and VA-ECMO. Baseline lactate of 3 mmol/L. | Yes (at time of PCI) SCAI stage E |
Survived | Accidental dislodgement of arterial cannula during CPR, requiring covered stent to right femoral artery and blood transfusion | – | |
| 65M | NSTEMI with biventricular failure and moderate-to-severe mitral regurgitation. Baseline lactate of 3 mmol/L. | No SCAI stage D |
Yes | Survived | – | |
| 60M | NSTEMI, multivessel disease, no attempt at PCI, progressive shock, biventricular dysfunction, renal failure, liver dysfunction. Peripheral VA-ECMO insertion, transferred to local transplant centre. Baseline lactate of 4 mmol/L. | No SCAI stage D |
Yes | Yes, hemorrhagic stroke after LVAD | – | |
| 40M | New nonischemic cardiomyopathy, progressive shock, Peripheral VA-ECMO insertion. Transferred to local transplant centre for further care. With recovery of LV function 8 days support. ICD inserted. Baseline lactate of 6 mmol/L. |
Yes SCAI stage D |
Yes | Survived, transferred to local transplant centre | Venous catheter dislodgement in catheterization laboratory, hematoma later infected. Arterial stenosis/mild claudication | – |
IABP, intra-aortic balloon pump; CP, cardiac power; CPR, cardiopulmonary resuscitation; CS, cardiogenic shock; ICD, implantable cardioverter defibrillator; LAD, left anterior descending artery; LV, left ventricle; LVAD, left ventricular assist device; MCS, mechanical circulatory support; NSTEMI, non–ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; RV-D, right ventricular dysfunction; SCAI, Society of Cardiovascular Angiography and Interventions; STEMI, ST-segment elevation myocardial infarction; VA-ECMO, venoarterial extracorporeal membrane oxygenation; VSD, ventricular septal defect; VV, veno-venous.
∗
Impella Systems (Abiomed, Danvers, MA).