Background: Takotsubo syndrome (TS) is an acute heart failure syndrome with considerable risk of shock, resuscitation and death. Left ventricular (LV) ejection fraction is strongly reduced and LV end-diastolic pressure is increased in almost all cases. Catecholamines are considered to play a causal role for the disease and aggravate outflow tract obstruction. Therefore, management of TS with shock is often a therapeutic dilemma. Mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation increases afterload, while intra-aortic balloon pump induces or aggravates LV outflow tract obstruction in TS. In contrast, the Impella microaxial heart pump unloads the left ventricle and improves coronary and end-organ perfusion. Impella appears favourable for support in TS; however, data on the use of Impella in TS are lacking.
Hypothesis: Impella mechanical circulatory support in TS patients with shock is associated with favourable outcomes.
Methods: We retrospectively reviewed Impella patients at our institutions as well as in the cVAD registry to identify Impella-supported patients with TS. Patient characteristics and in-hospital outcomes were analysed.
Results: A total of 20 TS patients supported with an Impella pump (eight Impella 2.5, 11 Impella CP and one Impella 5.0) from six centres in Europe and five in the US were identified (age 61.5 ± 17.1 years, 80% women). The majority of patients had an apical TS type, and seven patients had a physical trigger. Seven patients had confirmed shock on admission. Patients were on catecholamines (1.9 ± 0.9) prior to Impella and had a mean systolic blood pressure of 100 ± 25 mmHg. Almost all patients (85%) were mechanically ventilated, and 37.5% sustained cardiac arrest requiring cardiopulmonary resuscitation prior to Impella. Lactate and pH before Impella were 4.1 ± 3.4 mmol/l and 7.30 ± 0.23, respectively. The median (interquartile range) support time was 2 (1–3.25) days. Of the 20 patients, 16 (80%) survived to discharge. Of those, 100% experienced myocardial recovery with a significant improvement of the LVEF at discharge compared to baseline (19.8% ± 8.5% on admission versus 54.3% ± 9.7% before discharge, p<0.001).
Conclusion: This is the first series of mechanical support with the Impella ventricular assist device in patients with TS and shock. In a cohort of patients with mainly refractory cardiogenic shock, Impella support was associated with remarkable survival and excellent myocardial recovery in survivors. Our data set the stage for prospective studies on Impella support in TS with shock.