Acceptable Post–Heart Transplant Outcomes Support Temporary MCS Prioritization in the New OPTN|UNOS Heart Allocation Policy
Heidi ReichDanny RamzyJ. MoriguchiS. DimbilRyan LevineElizabeth PassanoM. KittlesonRobert ColeL. CzerD. ChangD. GeftAlfredo TrentoJoanna ChikweJon KobashigawaF. Esmailian
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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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Temporary mechanical circulatory support (TCS) is recommended for patients with profound cardiogenic shock (CS). Extracorporeal membrane oxygenation (ECMO) and Impella are possible TCS devices, but the device choice and the implantation timing are not definitely established, specifically during acute myocardial infarction. We have analyzed the respective use of ECMO or Impella (2.5, CP, or 5.0) for CS following acute myocardial infarction, from a cohort of patients who underwent TCS within 72 hours after admission for emergency percutaneous coronary intervention (PCI) from January 2009 to April 2015. Among 88 TCS-treated patients, 42 had early TCS: 23 ECMO and 19 Impella. Cardiac management, including PCI, was similar between the two groups, but ECMO patients were sicker than Impella patients (higher blood lactate level at ICU admission, higher vasoactive-inotroic and ENCOURAGE scores before TCS implantation, p ≤ 0.02). Three patients (7%) have had TCS implantation before admission, but TCS was implanted mostly in cathlab (43%, 1 during PCI, 13 just after PCI) or soon after ICU admission (50%, n = 21). Modification of the initial TCS choice was required in 10 cases (24%) for assistance upgrading in case of Impella (n = 4) or for left ventricle unloading in case of ECMO (n = 6). Extracorporeal membrane oxygenation is the technique of choice in case of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise. Interestingly, the combination of both techniques may help to overcome the limits inherent to each device.
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Mechanical circulatory support (MCS) involves the use of intra-aortic balloon pump (IABP), short-term percutaneous ventricular assist devices, long-term surgically implanted continuous-flow ventricular assist devices (cf-LVADs), and extracorporeal membrane oxygenation (ECMO) for the treatment of acute and chronic heart failure and cardiogenic shock. IABP is increasingly recognized as an important adjunct in the postoperative treatment arsenal for those patients with severely reduced left ventricular systolic function. Short-term percutaneous options for the treatment of acute right and left heart failure include both the Impella and Tandem Heart, whereas the Centrimag is often used in the surgical setting for acute cardiogenic shock and heart failure. Long-term surgical MCS options include the total artificial heart and the cf-LVADs HeartWare and Heartmate II. ECMO is frequently used for the treatment of acute cardiogenic shock and may be placed peripherally via a percutaneous approach or with central cannulation. ECMO is also increasingly used in the setting of acute cardiac life support, known as extracorporeal life support. Key words: cardiac critical care, extracorporeal membrane oxygenation, long-term ventricular assist device, mechanical circulatory support, short-term ventricular assist device
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Abstract Cardiogenic shock from biventricular failure that requires acute mechanical circulatory support carries high 30 day mortality. Acute mechanical circulatory support can serve as bridge to orthotopic heart transplant (OHT) in selected patients. We report a patient with biventricular failure secondary to rapidly progressive cardiac sarcoidosis refractory to medical management who was bridged to OHT with Impella 5.0 and Impella RP—temporary left and right ventricular assist devices, respectively. This is the first successful bridge to transplantation using these devices in biventricular heart failure and cardiogenic shock. We discuss considerations for using this strategy over veno‐arterial extracorporeal membrane oxygenation or surgically implanted assist devices in patients with cardiogenic shock and biventricular failure as a bridge to OHT.
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BackgroundMechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock (CS) with an aim to improve survival outcomes. The aim of our meta-analysis is to compare mortality and morbidity outcomes with use of Impella versus extracorporeal membrane oxygenation (ECMO) in adult patients with CS.MethodsWe searched Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases (Inception to December 2021) for observational studies comparing Impella to ECMO in patients with CS. Risk ratio (RR) for categorical variables and standardized mean difference (SMD) for continuous variables with 95% confidence interval (CI) were calculated using a random-effects model.Results11 retrospective studies and one prospective study (Impella n=6547, ECMO n=1178) were identified. Impella use was associated with lower in-hospital mortality (RR 0.87, 0.80-0.96, p=0.004), lower stroke incidence (RR 0.30, 0.21-0.42, p<0.00001), and shorter length of ICU stay (SMD -0.35, -0.65 - -0.04, p=0.03). There was no significant difference in MCS duration, renal replacement therapy, mechanical ventilation, and baseline LVEF between Impella and ECMO groups.ConclusionsDisclosuresS. Ahmad Nothing to disclose. B. A. Khan Nothing to disclose. S. Muhammad Nothing to disclose. A. Yousaf Nothing to disclose. B. Abdelazeem Nothing to disclose. M. Ahmad Nothing to disclose. X. Tieliwaerdi Nothing to disclose. A. H. Qavi Nothing to disclose. BackgroundMechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock (CS) with an aim to improve survival outcomes. The aim of our meta-analysis is to compare mortality and morbidity outcomes with use of Impella versus extracorporeal membrane oxygenation (ECMO) in adult patients with CS. Mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock (CS) with an aim to improve survival outcomes. The aim of our meta-analysis is to compare mortality and morbidity outcomes with use of Impella versus extracorporeal membrane oxygenation (ECMO) in adult patients with CS. MethodsWe searched Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases (Inception to December 2021) for observational studies comparing Impella to ECMO in patients with CS. Risk ratio (RR) for categorical variables and standardized mean difference (SMD) for continuous variables with 95% confidence interval (CI) were calculated using a random-effects model. We searched Medline, EMBASE, Cochrane, and Clinicaltrials.gov databases (Inception to December 2021) for observational studies comparing Impella to ECMO in patients with CS. Risk ratio (RR) for categorical variables and standardized mean difference (SMD) for continuous variables with 95% confidence interval (CI) were calculated using a random-effects model. Results11 retrospective studies and one prospective study (Impella n=6547, ECMO n=1178) were identified. Impella use was associated with lower in-hospital mortality (RR 0.87, 0.80-0.96, p=0.004), lower stroke incidence (RR 0.30, 0.21-0.42, p<0.00001), and shorter length of ICU stay (SMD -0.35, -0.65 - -0.04, p=0.03). There was no significant difference in MCS duration, renal replacement therapy, mechanical ventilation, and baseline LVEF between Impella and ECMO groups. 11 retrospective studies and one prospective study (Impella n=6547, ECMO n=1178) were identified. Impella use was associated with lower in-hospital mortality (RR 0.87, 0.80-0.96, p=0.004), lower stroke incidence (RR 0.30, 0.21-0.42, p<0.00001), and shorter length of ICU stay (SMD -0.35, -0.65 - -0.04, p=0.03). There was no significant difference in MCS duration, renal replacement therapy, mechanical ventilation, and baseline LVEF between Impella and ECMO groups. Conclusions DisclosuresS. Ahmad Nothing to disclose. B. A. Khan Nothing to disclose. S. Muhammad Nothing to disclose. A. Yousaf Nothing to disclose. B. Abdelazeem Nothing to disclose. M. Ahmad Nothing to disclose. X. Tieliwaerdi Nothing to disclose. A. H. Qavi Nothing to disclose. S. Ahmad Nothing to disclose. B. A. Khan Nothing to disclose. S. Muhammad Nothing to disclose. A. Yousaf Nothing to disclose. B. Abdelazeem Nothing to disclose. M. Ahmad Nothing to disclose. X. Tieliwaerdi Nothing to disclose. A. H. Qavi Nothing to disclose.
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