Successful combined use of impella recover 2.5 device and intra-aortic balloon pump support in cardiogenic shock from acute myocardial infarction

Ventricular assist devices (VADs) and intra-aortic balloon pumps (IABPs) are important tools that provide hemodynamic support to patients in cardiogenic shock. The Impella Recover 2.5 is a percutaneous VAD that provides temporary circulatory support. We report the case of a patient who required the combined support of both an IABP and the Impella device. ASAIO Journal 2010; 56:519–521. Cardiogenic shock (CS) after an ST-elevation myocardial infarction (STEMI) is a lethal clinical condition, with a reported mortality of 65% in a recent series.1 Although intra-aortic balloon pump (IABP) support may sustain some patients, improvements in cardiac output are quite modest—approximately 0.5 L/min. Ventricular assist devices (VADs) have been the mainstay in patients who require a greater degree of hemodynamic support. Unfortunately, postinfarction and postcardiotomy VAD support carries a relatively high rate of mortality and morbidity.2 Percutaneous VADs, which can be placed in the catheterization laboratory, have recently been approved for the treatment of CS. One such device is the Impella Recover 2.5 (Impella Cardiosystems, AG, Aachen, Germany) in which the pump is deployed in a retrograde manner across the aortic valve. The pump is connected to a mobile control console and is capable of providing up to 2.5 L/min of support at its highest operating speed. This device is approved by Food and Drug Administration for partial circulatory support for periods up to 6 hours under a 510(k) exemption. A recent animal study published by Sauren et al. 3 suggests that combined use of the Impella Recover 2.5 and an IABP may provide synergistic support. Herein, we report the case of a patient with an STEMI complicated by medically refractory cardiogenic shock who underwent successful support with both devices and was successfully discharged home. CASE PRESENTATION The patient is a previously healthy 67-year-old woman who presented with an STEMI complicated by CS. Despite conventional pharmacotherapy for CS, the patient remained hemodynamically unstable with a mean arterial pressure (MAP) 50 mm Hg on high-dose vasopressor support. An electrocardiogram indicated an acute anterolateral STEMI and new left bundle branch block; transthoracic echocardiography revealed severe left ventricular dysfunction, with an ejection fraction (EF) of 10%, along with moderate mitral and tricuspid regurgitation. An IABP was percutaneously placed via the right femoral artery, and the patient was brought immediately to the cardiac catheterization laboratory. Cardiac catheterization showed an 80% proximal left anterior descending artery (LAD) lesion, a 95% mid-LAD stenosis with collateralization, a 100% mid-circumflex stenosis (the culprit lesion), and a completely occluded second obtuse marginal. Bare metal stents were placed in the proximal left circumflex artery, proximal left anterior descending artery, and the second obtuse marginal artery. Because of persistent shock despite revascularization and IABP support, an Impella Recover 2.5 was percutaneously placed via the left femoral artery. The logistics of the Impella insertion were as follows: the IABP was placed in “Pause” mode; the Impella was then inserted via the left femoral artery. Impella flow was titrated up to maximal support (2.5 L/min) to achieve a total cardiac output of 4 L/min. Because the patient’s MAP remained low even after Impella actuation, the IABP was reactivated.