Clinical paperPercutaneous left ventricular assistance in post cardiac arrest shock: Comparison of intra aortic blood pump and IMPELLA Recover LP2.5☆
Introduction
Out of hospital cardiac arrest (OHCA) still remains a major public health concern. The overall survival rate remains low and is critically related to the delay of initiation of resuscitation. Even in patients with successful resuscitation, the prognosis remains poor, due to cerebral ischemic injury and occurrence of post-cardiac arrest syndrome.1 Post-cardiac arrest (CA) shock is characterized by a systemic ischemia/reperfusion syndrome but also by a low cardiac output provoked by a transient myocardial stunning. This may lead to shock, multiple organ failure (MOF) and death, even in patients with good neurological prognosis. In the setting of OHCA related to acute coronary syndrome (ACS), cardiac function is furthermore impaired in relation to the extent of necrosis. The cornerstone of the initial care is thus early reperfusion.2 Providing early cardiac mechanical assistance after OHCA may unload left ventricle (LV) and increase cardiac output.1, 3 This strategy may even help in resolution of shock and limit further secondary cerebral injury related to hypoperfusion. Cardiac assistance may help to overcome the initial myocardial failure and thereafter enable secondary neurological evaluation. Extracorporeal life support (ECLS) has been proposed in refractory cardiac arrest and refractive shock but is technically complex and requires surgical approach.4 Furthermore the cost-effectiveness of ECLS remains uncertain in this population at high risk for major brain damages. There is therefore a need for minimally invasive assistance devices in the setting of post-cardiac arrest shock. For years, intra-aortic balloon pump has been considered as adjunctive therapy in cardiogenic shock, especially during ACS.6 This could be extended to post-CA shock despite the lack of current evidence.5, 6 The IMPELLA Recover LP2.5 (ABIOMED Europe GmbH, Aachen, Germany) was recently developed as a catheter-based miniaturized axial flow pump that may be inserted percutaneously. Safety and feasibility of IMPELLA LP2.5 has been previously evaluated in high-risk percutaneous coronary intervention (PCI)7, 8 and was also compared to IABP in a small trial of patients with cardiogenic shock.9 In order to better evaluate the potential benefit of this left ventricular assist device in the very particular setting of post-CA patients, we report here our experience regarding outcome, feasibility and safety of the use of the IMPELLA LP2.5 compared to IABP.
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Materials ands methods
The study was based on analysis of the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry, which was previously described.10 Patients were enrolled from January 2007 to October 2010 at the Cochin University Hospital (Paris, France), which is considered a specialized cardiac arrest center. All OHCA patients were managed by mobile emergency units, each staffed with a physician trained in emergency medicine. All pre-hospital survivors with no obvious extra-cardiac cause were directly
Results
From January 2007 to October 2010, 576 patients were admitted in our center after OHCA. In 356 patients, emergent coronary angiogram was performed in the absence of an obvious extra-cardiac cause. Among them, a total of 78 patients underwent LV mechanical assistance with a percutaneous device (22%), with 35 patients considered for IMPELLA implantation and 43 for IABP. Baseline characteristics of the two populations are reported in Table 1A. No significant differences in baseline characteristics
Discussion
In this retrospective study, we report for the first time a local experience with the IMPELLA LP2.5 in survivors of OHCA. We observed an excellent feasibility (97%) associated with a 23% survival rate at 28 days in this population at a high risk of death. The specificity of this study is to have initiated assistance early after OHCA onset. Most of the patients received IMPELLA support in the three hours after collapse, a time lower than previous LVAD trials in patients with cardiogenic shock.18
Conclusion
In this small study, the use of the IMPELLA Recover LP2.5 was evaluated in 35 survivors of OHCA with post-resuscitation shock or predictive factors for the occurrence of shock and compared to 43 patients assisted by IABP. The device was successfully implanted in 97% of the cases for a median duration of 14 h. Bleeding at the insertion site was the main safety concern compared to IABP: 26% vs 9% of patients requiring transfusion. With respect to the difference of severity of the two populations,
Conflict of interest statement
Dr. Manzo-Silberman and Profs. Cariou and Spaulding received lectures fees from ABIOMED Europe GmbH (Aachen, Germany).
Acknowledgments
The authors thank all the staff members from the interventional cardiology department and from the intensive care unit.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.001.
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These authors contributed equally to this work and are co-first authors of this manuscript.