Background: Peripheral veno-arterial extracorporeal life support (ECLS) for cardiogenic shock has been shown to improve survival in patients in need of biventricular and lung failure, but is associated with complications. The Impella 5.0 seems to be a less invasive, but equivalent, haemodynamic alternative if right ventricular function allows switching from extracorporeal membrane oxygenation to Impella 5.0 and allows left ventricular (LV) unloading.
In patients with unclear neurological situations, ECLS should be discontinued promptly if there is no hope for healthy survival, according to Extracorporeal Life Support Organization guidelines. However, durable left ventricular assist device (LVAD) implantation is contraindicated in patients with unclear neurological outcomes, according to the International Society for Heart and Lung Transplantation recommendations. Impella 5.0 therapy might reduce ECLS-related complications and allow further evaluation of the neurological situation and further treatment options.
Methods: We retrospectively reviewed 30 patients (mean age 56.5 ± 10.7 years) who were in need of ECLS and underwent Impella 5.0 implantation after recovery of the right ventricular and pulmonary function with unclear neurological outcome between January 2016 and July 2018 in our institution. Neurological function was measured by cerebral performance category and modified Rankin scale.
Results: Twenty-six patients had prior cardiopulmonary resuscitation before ECLS implantation. The mean duration of cardiopulmonary resuscitation was 67.4 ± 32.3 minutes. Twenty-two patients had acute MI. The mean time on ECLS before Impella 5.0 implantation was 9.3 ± 1.7 days. Eighteen patients (60.0%) had concomitant Impella 2.5/CP treatment for LV unloading. All patients have been successfully weaned from ECLS and received Impella 5.0 implantation using the axillary artery. The mean time on Impella 5.0 alone was 16.3 ± 4.7 days. Seven patients have been bridged to a permanent LVAD. In 10 patients, myocardial function recovered and the Impella 5.0 has been explanted. The 30-day survival was 66.7%. Bleeding complications on ECLS improved in 75% after the switch to Impella 5.0, and 73.3% of patients were able to be extubated and mobilised after Impella 5.0 implantation. Both quantitative measures of cerebral performance improved after 30 days (p<0.01).
Conclusion: Impella 5.0 provides a good bridge-to-decision option for patients who, after ECLS implantation, have a recovered RV and lung function and leads to LV unloading. It is an ideal solution to avoid ECLS-related complications, such as bleeding and limb ischaemia. Impella 5.0 therapy allows further evaluation of the neurological situation and further therapy after ECLS therapy. Almost two-thirds of patients survived with good neurological outcomes after Impella 5.0 therapy.