Author + information
- Joern Tongers1,
- Jan-Thorben Sieweke1,
- L Christian Napp1,
- Florian Zauner1,
- Dominik Berliner1,
- Christian Kühn2,
- Axel Haverich2,
- Johann Bauersachs1 and
- Andreas Schäfer1
Despite advances in management of cardiogenic shock (CS), its mortality remains unacceptably high particularly if refractory. The evolving field of mechanical support including extracorporeal membrane oxygenation (ECMO) and Impella microaxial pump has revolutionized treatment strategies. However, questions regarding mechanical support such as timing and management remain elusive. Experience in the combination of ECMO and Impella intending on biventricular unloading are lacking.
In our single-center registry, 55 consecutive patients with refractory CS received dual mechanical support using Impella and veno-arterial (VA) ECMO (female-male 18/82%, age 53±2 yrs). Cardiogenic shock resulted from cardiomyopathy (40%), STEMI (17%), NSTEMI (7%), and arrhythmia (15%). During the ICU-course patients were critically ill: e.g. 93% mechanical ventilation, 53% dialysis, 38% resuscitation. Impella and VA ECMO were inserted and removed percutaneously via femoral access (duration of dual support: 107±72 hrs).
The length of ICU-/in-hospital stay was 12±2 and 27±5 days. On mechanical support, hemodynamics stabilized, while use of catecholamines could be saved (dobutamine: BL 5.6±4.2, 24-hrs 2.9±3.1, 72-hrs 2.2±2.7 mg/kg/min, p<0.0001 vs. BL; norepinephrine BL 0.5±0.6, 24-hrs 0.2±0.3, 72-hrs 0.2±0.3 mg/kg/min, p<0.0001 vs. BL). Reflecting the microcirculation, lactate levels normalized over time (BL 8.5±6.4, 24-hrs 2.4±1., 72-hrs 2.1±2.4 mmol/L, all p<0.05 vs. BL). Despite the negative selection of CS patients with a historically devastating prognosis, in-hospital survival in our fragile population was 42%. While 19 patients were bridged to recovery, 13 patients were bridged to VAD-implantation. After its successful weaning mechanical support had not to be reinstalled in any patient. The safety profile of dual support was reasonable (e.g. 11% DIC, 7% leg ischemia, 7% stroke, 6% compartment). Vascular access site problems occurred in only 3 patients.
In conclusion, the concept of dual mechanical support using Impella microaxial pump combined with VA ECMO for biventricular unlading in refractory CS is feasible and efficient in stabilizing and rescuing patients at highest risk.
CORONARY: Hemodynamic Support and Cardiogenic Shock