Cardiogenic shock: From ECMO to Impella and beyond
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For patients in cardiogenic shock, several devices can serve as a “bridge,” ie, provide circulatory support and allow the patient to live long enough to recover or to receive a heart transplant or a long-term device. Options include an intraaortic balloon pump, TandemHeart, Impella, extracorporeal membrane oxygenation (ECMO), and CentriMag. Which device to use depends on individual patient needs, local expertise, and anatomic and physiologic considerations.Keywords:
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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.
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Cardiogenic shock remains a serious complication of acute myocardial infarction as it is associated with very poor prognosis. Despite the historical clinical benefits of the intra-aortic balloon pump (IABP), in some patients additional mechanical cardiac support is necessary. The recent introduction of the percutaneous Impella® 2.5 mechanical circulatory support system (Abiomed Inc., Danvers, MA, USA) represents a major advancement and has been used in these circumstances. Nevertheless, the data supporting the use of this technology alone, after, or in combination with the IABP in patients with cardiogenic shock is limited and the clinical benefits remain unproven. We herein provide an updated comprehensive overview of the literature supporting the use of the Impella 2.5 system compared to the use of IABP in patients with cardiogenic shock. We also discuss the potential role for combination therapy for a patient with refractory shock. We describe a case in which an IABP was used as a bail-out strategy to provide additional haemodynamic support in a patient with refractory cardiogenic shock after the Impella 2.5 system was in place. In selected cases of refractory cardiogenic shock, the use of combined therapy with both the the Impella 2.5 and IABP can provide enhanced circulatory support and could be considered an option to maintain haemodynamic support in these patients.
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For patients in cardiogenic shock, several devices can serve as a “bridge,” ie, provide circulatory support and allow the patient to live long enough to recover or to receive a heart transplant or a long-term device. Options include an intraaortic balloon pump, TandemHeart, Impella, extracorporeal membrane oxygenation (ECMO), and CentriMag. Which device to use depends on individual patient needs, local expertise, and anatomic and physiologic considerations.
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Despite recent advances in the management of heart failure, cardiogenic shock remains a challenging and devastating condition with significant morbidity and mortality.We review currently available percutaneous mechanical circulatory support (MCS) devices and address each device's characteristics, mechanism of action, specific clinical indications, and contraindications.Four types of percutaneous MCS devices are currently available: the intraaortic balloon pump (IABP), Impella devices, the TandemHeart, and extracorporal membrane oxygenation (ECMO). IABPs provide less hemodynamic support compared to the Impella, TandemHeart, and ECMO devices. However, because of its ease of placement and relatively small access catheter size, the IABP remains the most commonly used MCS device for the treatment of cardiogenic shock. When full cardiopulmonary support is needed, ECMO is the best option.Temporary MCS has emerged as a therapeutic option in the management of patients with acute cardiogenic shock. However, clinician familiarity with the indications, limitations, and benefits of individual MCS devices and enhanced patient comfort with the placement are paramount to improve patient outcomes.
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HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not.The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. Surgical technique for the implantation of mechanicalcirculatory support with the Impella 5.0 pump in a patient with post-cardiotomy cardiogenic shock
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An increasing number of patients with complex coronaryartery anatomy, including the left main coronaryartery, are being treated with percutaneous coronaryinterventions.Ventricular assist devices (VADs) may be useful forpatients at risk of developing hemodynamic instabilityor for those with cardiogenic shock (CS) due to acoronary event. Yet, the role and the superiority ofVAD over intraaortic balloon pump (IABP) are notcompletely defined.
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Intra-aortic balloon pump (IABP) has been used for many years in high-risk PCI or cardiogenic shock. However, the support provided by IABP is limited and a major randomised controlled trial failed to demonstrate a beneficial effect.1 Impella® is a family of percutaneous mechanical circulatory support (MCS) devices that are used in protected PCI and cardiogenic shock.2 Depending on the device model, they provide a blood flow ranging from 2.5 to 5 L/min. The resulting augmented support increases mean arterial blood pressure, cardiac output and coronary flow while unloading left ventricular filling pressure to reduce myocardial oxygen demand.2 3 This is an ideal form of temporary support device for the patient. Moreover, the device is easy to set up and can be inserted very quickly to stabilise the patient. This presentation provides a review on the current data regarding the use of Impella MCS devices.
References
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