Impella LVAD for pre/post CABG 2/2 Cardiogenic shock.

[sevoflurane]

I've seen these come to the CT OR after failed PCI. Most recently, occluded PDA, LAD, and Circ that was not suitable for PCI. This patient presented to the ED in cardiogenic shock and EF of 10%.

I work at an istitution that does not provide heartmate II L/Rvads, ECMO, Tandemheart, etc.

The cardiac labs do place Impella's however.

What is your experience and do you like it?

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[sethco]

Seems like good substitute if your institution does not do Heartmates and you are temporizing until either recovery or transfer to another location for implantable LVAD/transplant. However, in the setting your describing, why doesn't the cath lab just place an IABP instead? It seems likely to be lower risk, i.e. avoiding LV inflow obstruction, AV damage, etc.? I have only seen two impellas placed during fellowship, so dont have that much experience with it.

 

[G0S2]

I believe Impella recently shown to be superior to IABP.

 

[bigdan]

My Impella experience has been that the 2.5's are often just not enough support to get patients "over the hump"; my hospital does a ton of VADs, so we tend to see patients in the ICUs with LVADs as opposed to the centrally placed 5.0s. The Impella 2.5 seems to be enough to get patients to our ICUs from other hospitals, but we seem to rarely sit on them very long, as they often need immediate intervention. I suppose, in that sense, I like them, since it gets the patient to us, but it wouldn't routinely get the patient that Sevo's describing through the night, in my humble opinion. IF the patient can get to the OR, get a 5.0 - that's enough flow to give the patient some time to rest/heal/transfer.

I don't see the IABP as interchangeable with Impella - if the heart is just too weak/damaged to push flow forward, the IABP won't help much.

*Thread detour* - sethco - congrats on boards; are you staying in Texas?

 

[sevoflurane]

We use the 5.0.

While achieving flows as high as 4-5 l/min is exceptional for this type of device and case, I do have a couple of squables with it:

1) Anticoagulation post-bypass. While ACT of 170s isn't the end of the world, in a critical patient that has altered clotting ability, this may prove to be more than annoying.
2) Proximal inflow occlusion. You don't get that with an IABP.
3) Potential for aortic valve damage as well as the subvalvular mitral apparatus. LV damage (especially septal wall). Aortic dissection when placing the device, and then putting them on a heparin drip. This is all in the setting of an already diseased heart coming to the CT OR for a "salvage" cabg.
4) You also need to pull it back prior to cross-clamp. Not a big deal with TEE, but another pass through the aortic valve after unclamping.

Just thinking out loud. The device certainly does what it's supposed to.

 

[sethco]

My Impella experience has been that the 2.5's are often just not enough support to get patients "over the hump"; my hospital does a ton of VADs, so we tend to see patients in the ICUs with LVADs as opposed to the centrally placed 5.0s. The Impella 2.5 seems to be enough to get patients to our ICUs from other hospitals, but we seem to rarely sit on them very long, as they often need immediate intervention. I suppose, in that sense, I like them, since it gets the patient to us, but it wouldn't routinely get the patient that Sevo's describing through the night, in my humble opinion. IF the patient can get to the OR, get a 5.0 - that's enough flow to give the patient some time to rest/heal/transfer.

I don't see the IABP as interchangeable with Impella - if the heart is just too weak/damaged to push flow forward, the IABP won't help much.

*Thread detour* - sethco - congrats on boards; are you staying in Texas?

I definitely agree that the Impella and the IABP are not interchangeable. The Impella certainly generates more reliable cardiac output. However, I was just thinking that the IABP would be lower risk, especially in the setting of ischemic cardiomyopathy. Both are purely temporizing measures.

Anyway, congrats on boards. Yeah, I will be doing PP hearts in the Dallas area, but with a mixed practice. Are you getting ready to go to Cleveland next year?

 

[Stank811]

Agreed with everything stated. We have run impellas with heparin in the purge solution only with ACT in the 130-150's for days in the setting of bleeding. Impella 5.0 at my institution are placed with a cut down to axillary or subclavian artery. Complications include: subclavian vein thrombosis, subclavian artery stenosis/thrombosis after removal, flailed mitral leaflet secondary to tearing chordea, and LV thrombosis. Interestingly not one of the thrombosis events was in a patient that we were running low ACTs.

 

[OB1🤙]

We've had good experience with the Impella 5.0 in these situations. Our shop has ECMO but not LVADs (yet) or transplants.

I can recall two recent successes we had. One was rejection post-transplant, the Impella bought time as a bridge to recovery via anti-rejection meds. Was successfully decannulated. The second case was NICM, the Impella made possible transfer to a transplant center.

It's definitely much better than an IABP. Management requires more finesse, as in how to manage suction events and the like.

We also do these via axillary cut down.

 

[periopdoc]

We used the surgically implanted Impella LD during residency and fellowship. 5 LPM and frequently it was enough to get patients over the hump. Loved it.

Haven't had the opportunity to use the minimally invasive 2.5 or 5, but I can certainly believe that 2.5 might not be enough. There is a newish (Approved late 2012) Impella CP that can be inserted transfemorally and provides 4 LPM. I am betting that this will be a good happy medium for use in the heart room.

I have been thinking about pushing our institution to get these.

- pod

 

[seinfeld]

A Lot of experience in fellowship with all sorts of LVADs including the impella, never was really impressed by it. Currently we have IABPs, ECMO, and temp VADs

The big question I have is whether flogging a heart with a bunch of inotropes and pressors is better/worse/same as using early mechanical support. Recently published, retrospective propsensity matched cohort, article in Anesthesiology suggesting that inotropes worsen 1 year mortality. Should mechanical support come first?