Short communicationThe Impella CP device for acute mechanical circulatory support in refractory cardiac arrest☆
Introduction
Despite improvements in cardiopulmonary resuscitation (CPR) procedures refractory cardiac arrest (rCA) remains associated with very high mortality rates. Mechanical circulatory support with Veno-Arterial Extra Corporal Membrane Oxygenation (VA-ECMO) is considered a promising treatment for patients with rCA.1
VA-ECMO support in rCA patients is; however, associated with a number of complications including cannulation related complications and uncontrolled bleeding.2 Also, VA-ECMO does not reduce left ventricular (LV) afterload and wall stress which may adversely reduce LV recovery.3
The left ventricular assist device Impella CP® propels blood from the LV cavity into the ascending aorta with continuous non-pulsatile flow thereby reducing left ventricular volume and walls stress. In a porcine model of cardiac arrest the Impella® device led to doubled rates of return of spontaneous circulation and a better cardiac functional outcome in the early post-arrest period.4
There is to our knowledge no human data on the effect of mechanical support with the Impella device in patients with rCA.
We here report our first experiences and results with the Impella CP® device in selected patients with rCA.
Section snippets
Methods
This report comprises a dual case series of all patients with rCA (N = 8) and cardiogenic shock (N = 12) treated with the Impella® device (Abiomed, Inc., Danvers, MA, USA) at Aarhus University Hospital, Denmark from November 2014 to October 2015.
The Impella CP® was used at the discretion of the treating physicians in patients with rCA and pulseless electrical activity (PEA) with presumed primary left ventricular failure. Patients were either already in or transferred to the Cath. Lab. under
Results
Patient and procedural characteristics are shown in Table 1.
The Impella device was successfully inserted in all patients.
Individual patient peri-arrest characteristics are displayed in Table 2. All arrests were witnessed and manual CPR was initiated immediately. Although several patients achieved brief intermittent ROSC, all patients had had PEA for more than 10 min at the time of Impella insertion. Peri-arrest arterial pH and plasma lactate were 7.02 ± 0.11 and 12 ± 4 mmol/L respectively. All
Discussion
This paper comprises our experiences and results with mechanical circulatory support with the Impella CP® device in selected patients with rCA. This is to our knowledge the first report of using the Impella device in this clinical setting. Circulation was restored in all patients leading to a 50% survival with a good neurological outcome. Vascular complications were; however, more frequent compared with the use of Impella in patients with cardiogenic shock.
VA-ECMO is considered a promising
Conclusion
Mechanical support with the Impella CP® device is a feasible and promising treatment option for selected patients with rCA. Further studies are warranted to determine the full potential and optimal patient selection compared to other modalities of mechanical circulatory support.
Conflict of interest statement
We declare no conflicts of interest.
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Cited by (38)
Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support
2022, Resuscitation PlusCitation Excerpt :In recent years, high-impact literature on the use of ECPR for refractory OHCA has surfaced as two randomized clinical trials and a meta-analysis have been conducted.23–25 Conversely, evidence for Impella in refractory OHCA is largely limited to case-series and observational single-centre experiences.26–28 Latest guidelines do not recommend routine use of V-A ECMO in refractory OHCA; however, ECMO may be considered in selected patients with a potentially reversible cause of arrest.9,29
European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances
2021, ResuscitationCitation Excerpt :Delivering quality manual CPR in the catheterisation laboratory may be challenging due to the presence of the X-ray tube, and may expose the rescuer harmful radiation; for this reason, mechanical CPR should be considered. Percutaneous ventricular assist devices such as intra-aortic balloon pump, Impella® 447 or TandemHeart® may provide circulatory support while performing rescue procedures during cardiac arrest, although their use in this setting has not been extensively evaluated. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) offers both circulatory and pulmonary support and may be used in cardiac arrest (extracorporeal life support: ECPR), but there is insufficient evidence to systematically recommend such strategy.238
Short term outcomes of Impella in cardiogenic shock: A review and meta-analysis of observational studies
2021, International Journal of CardiologyCitation Excerpt :Older patients and female gender were associated with an increased risk of such complications. These aspects were already highlighted by other authors suggesting a key role of peripheral artery disease in old patients and the small artery size in women [24], futher in patients with CS the vasopressors related vasoconstriction may result in enhanced complications. Also the urgency setting, which is typically present in a cardiogenic shock scenario, jeopardize the opportunity for dedicated access assessment compared to the elective procedure [25].
Selective Aortic Arch Perfusion
2021, Rich’s Vascular Trauma
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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.2016.10.003.