1
|
Mardini MT, Bai C, Bledsoe M, Shickel B, Al-Ani MA. An explainable machine learning approach using contemporary UNOS data to identify patients who fail to bridge to heart transplantation. Front Cardiovasc Med 2024; 11:1383800. [PMID: 38832313 PMCID: PMC11144884 DOI: 10.3389/fcvm.2024.1383800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/30/2024] [Indexed: 06/05/2024] Open
Abstract
Background The use of Intra-aortic Balloon Pump (IABP) and Impella devices as a bridge to heart transplantation (HTx) has increased significantly in recent times. This study aimed to create and validate an explainable machine learning (ML) model that can predict the failure of status two listings and identify the clinical features that significantly impact this outcome. Methods We used the UNOS registry database to identify HTx candidates listed as UNOS Status 2 between 2018 and 2022 and supported with either Impella (5.0 or 5.5) or IABP. We used the eXtreme Gradient Boosting (XGBoost) algorithm to build and validate ML models. We developed two models: (1) a comprehensive model that included all patients in our cohort and (2) separate models designed for each of the 11 UNOS regions. Results We analyzed data from 4,178 patients listed as Status 2. Out of them, 12% had primary outcomes indicating Status 2 failure. Our ML models were based on 19 variables from the UNOS data. The comprehensive model had an area under the curve (AUC) of 0.71 (±0.03), with a range between 0.44 (±0.08) and 0.74 (±0.01) across different regions. The models' specificity ranged from 0.75 to 0.96. The top five most important predictors were the number of inotropes, creatinine, sodium, BMI, and blood group. Conclusion Using ML is clinically valuable for highlighting patients at risk, enabling healthcare providers to offer intensified monitoring, optimization, and care escalation selectively.
Collapse
Affiliation(s)
- Mamoun T. Mardini
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Chen Bai
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Maisara Bledsoe
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States
| | - Benjamin Shickel
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mohammad A. Al-Ani
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States
| |
Collapse
|
2
|
Pieri M, D'Andria Ursoleo J, Nardelli P, Ortalda A, Ajello S, Delrio S, Fominskiy E, Scandroglio AM. Temporary mechanical circulatory support with Impella in cardiac surgery: A systematic review. Int J Cardiol 2024; 396:131418. [PMID: 37813286 DOI: 10.1016/j.ijcard.2023.131418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/22/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Perioperative cardiogenic shock (CS) in cardiac surgery is still burdened by a high mortality risk. The introduction of Impella pumps in the therapeutic armory of temporary mechanical circulatory support (tMCS) has potential implications to improve the management of complex cases, although it has never been systematically addressed. We performed a systematic review of the reported use of tMCS with Impella in cardiac surgery. METHODS We searched PubMed for all original studies on the Impella use in adult patients in cardiac surgery. RESULTS Nineteen studies (out of 151 identified by search string) were included. All studies were observational and all but one (95%) were retrospective. Seven studies focused on the implantation of Impella in the pre-operative setting (coronary or valvular surgery), either as a prophylactic device in high-risk cases (3 studies) or in patients with CS as stabilization tool prior to cardiac surgery procedure (4 studies). Three studies reported the use of Impella as periprocedural support for percutaneous valvular procedure, three as bridge to heart replacement, and six for postcardiotomy CS. Impella support had a low complication rate and was successful in supporting hemodynamics pre-, intra- and postoperatively. Most consistently reported data were left-ventricular ejection fraction at implant, short-term survival and weaning rate. CONCLUSIONS tMCS with Impella in cardiac surgery patients is feasible and successful. It can be applied in selected cardiac surgery patients and presents advantages over other types of support. Systematic prospective studies are needed to standardize indications for implant and management of surgical issues, and to identify which patients may benefit.
Collapse
Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy.
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Silvia Ajello
- Department of Cardiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Silvia Delrio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| |
Collapse
|
3
|
Sicke M, Modi S, Hong Y, Bashline M, Klass W, Horn E, Hansra BS, Ramanan R, Fowler J, Sumzin N, Rivosecchi RM, Chaudhary R, Ziegler LA, Hess NR, Agrawal N, Kaczorowski DJ, Hickey GW. Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5. Int J Artif Organs 2024; 47:8-16. [PMID: 38053245 PMCID: PMC10824236 DOI: 10.1177/03913988231214180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Despite historical differences in cardiogenic shock (CS) outcomes by etiology, outcomes by CS etiology have yet to be described in patients supported by temporary mechanical circulatory support (MCS) with Impella 5.5. OBJECTIVES This study aims to identify differences in survival and post-support destination for these patients in acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) CS at a high-volume, tertiary, transplant center. METHODS A retrospective review of patients who received Impella 5.5 at our center from November 2020 to June 2022 was conducted. RESULTS Sixty-seven patients underwent Impella 5.5 implantation for CS; 23 (34%) for AMI and 44 (66%) for ADHF. AMI patients presented with higher SCAI stage, pre-implant lactate, and rate of prior MCS devices, and fewer days from admission to implantation. Survival was lower for AMI patients at 30 days, 90 days, and discharge. No difference in time to all-cause mortality was found when excluding patients receiving transplant. There was no significant difference in complication rates between groups. CONCLUSIONS ADHF-CS patients with Impella 5.5 support have a significantly higher rate of survival than patients with AMI-CS. ADHF patients were successfully bridged to heart transplant more often than AMI patients, contributing to increased survival.
Collapse
Affiliation(s)
- McKenzie Sicke
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shan Modi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Michael Bashline
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wyatt Klass
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ed Horn
- Department of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barinder S Hansra
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nikita Sumzin
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahul Chaudhary
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luke A Ziegler
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Nishant Agrawal
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Gavin W Hickey
- Division of Cardiology Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
4
|
Al-Ani MA, Bai C, Bledsoe M, Ahmed MM, Vilaro JR, Parker AM, Aranda JM, Jeng E, Shickel B, Bihorac A, Peek GJ, Bleiweis MS, Jacobs JP, Mardini MT. Utilization of the percutaneous left ventricular support as bridge to heart transplantation across the United States: In-depth UNOS database analysis. J Heart Lung Transplant 2023; 42:1597-1607. [PMID: 37307906 DOI: 10.1016/j.healun.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/12/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Intra-aortic balloon pump (IABP) and Impella device utilization as a bridge to heart transplantation (HTx) have risen exponentially. We aimed to explore the influence of device selection on HTx outcomes, considering regional practice variation. METHODS A retrospective longitudinal study was performed on a United Network for Organ Sharing (UNOS) registry dataset. We included adult patients listed for HTx between October 2018 and April 2022 as status 2, as justified by requiring IABP or Impella support. The primary end-point was successful bridging to HTx as status 2. RESULTS Of 32,806 HTx during the study period, 4178 met inclusion criteria (Impella n = 650, IABP n = 3528). Waitlist mortality increased from a nadir of 16 (in 2019) to a peak of 36 (in 2022) per thousand status 2 listed patients. Impella annual use increased from 8% in 2019 to 19% in 2021. Compared to IABP, Impella patients demonstrated higher medical acuity and lower success rate of transplantation as status 2 (92.1% vs 88.9%, p < 0.001). The IABP:Impella utilization ratio varied widely between regions, ranging from 1.77 to 21.31, with high Impella use in Southern and Western states. However, this difference was not justified by medical acuity, regional transplant volume, or waitlist time and did not correlate with waitlist mortality. CONCLUSIONS The shift in utilizing Impella as opposed to IABP did not improve waitlist outcomes. Our results suggest that clinical practice patterns beyond mere device selection determine successful bridging to HTx. There is a critical need for objective evidence to guide tMCS utilization and a paradigm shift in the UNOS allocation system to achieve equitable HTx practice across the United States.
Collapse
Affiliation(s)
- Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida.
| | - Chen Bai
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| | - Maisara Bledsoe
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Eric Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Benjamin Shickel
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Giles J Peek
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mark S Bleiweis
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mamoun T Mardini
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| |
Collapse
|
5
|
Gong TA, Hall SA. Challenges with the current United Network for Organ Sharing heart allocation system. Curr Opin Organ Transplant 2023; 28:355-361. [PMID: 37595099 DOI: 10.1097/mot.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
PURPOSE OF REVIEW The revised United States heart organ allocation system was launched in October 2018. In this review, we summarize this United Network for Organ Sharing (UNOS) policy and describe intended and unintended consequences. RECENT FINDINGS Although early studies published after the change suggested postheart transplant survival declined at 6 months and 1 year, recent publications with longer follow-up time have confirmed comparable posttransplant survival in adjusted models and several patient cohorts. Moreover, the new allocation decreased overall waitlist time from 112 to 39 days ( P < 0.001). Mean ischemic time increased because of greater distances traveled to acquire donor hearts under broader sharing. Despite the intention to decrease exception requests by expanding the number of priority tiers to provide more granular risk stratification, ∼30% of patients remain waitlisted under exception status. Left-ventricular assist device (LVAD) implants are declining and the number of LVAD patients on the transplant list has decreased dramatically after the allocation system change. SUMMARY As the next allocation system is developed, it is imperative to curtail the use of temporary mechanical support as a strategy solely for listing purposes, identify attributes that more clearly stratify the severity of illness, provide greater oversight of exception requests, and address concerns regarding patients with durable LVADs.
Collapse
Affiliation(s)
- Timothy A Gong
- Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Division of Cardiology, Department of Advanced Heart Failure, Mechanical Support, and Transplant, Baylor Heart and Vascular Hospital, Dallas
- Texas A&M University College of Medicine, Bryan, Texas
| | - Shelley A Hall
- Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Division of Cardiology, Department of Advanced Heart Failure, Mechanical Support, and Transplant, Baylor Heart and Vascular Hospital, Dallas
- Texas A&M University College of Medicine, Bryan, Texas
| |
Collapse
|
6
|
Condello I, Basile M, Speziale G. Theoretical Considerations on Cavitation During Microaxial Left Ventricular Assist Device. Ann Thorac Surg 2023; 115:800-801. [PMID: 35460618 DOI: 10.1016/j.athoracsur.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Ignazio Condello
- Department of Cardiovascular Surgery, GVM Care & Research, Perfusion Service, Anthea Hospital, Via Camillo Rosalba 35/37, 70124 Bari, Italy.
| | - Marco Basile
- Section of Cardiology, Ospedale Della Murgia "Fabio Perinei", Altamura, Italy
| | - Giuseppe Speziale
- Department of Cardiovascular Surgery, GVM Care & Research, Anthea Hospital, Bari, Italy
| |
Collapse
|
7
|
Nordan T, Kapur NK, Kawabori M. Cavitation During Microaxial Left Ventricular Assist Device Is Worth Considering. Ann Thorac Surg 2023; 115:801. [PMID: 35718197 DOI: 10.1016/j.athoracsur.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Taylor Nordan
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Navin K Kapur
- Division of Cardiology, CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Masashi Kawabori
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, 800 Washington St, Boston, MA 02111.
| |
Collapse
|
8
|
Abiragi M, Singer-Englar T, Cole RM, Emerson D, Esmailian F, Megna D, Moriguchi J, Kobashigawa JA, Kittleson MM. Temporary Mechanical Circulatory Support in Patients with Cardiogenic Shock: Clinical Characteristics and Outcomes. J Clin Med 2023; 12:jcm12041622. [PMID: 36836157 PMCID: PMC9965226 DOI: 10.3390/jcm12041622] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Patients with cardiogenic shock may require stabilization with temporary mechanical circulatory support (tMCS) to assess candidacy for definitive therapy, including heart transplantation (HTx) or durable MCS, and/or maintain stability while on the HTx waiting list. We describe the clinical characteristics and outcomes of patients with cardiogenic shock who underwent intra-aortic balloon pump (IABP) vs. Impella [Abiomed, Danvers, MA, USA] placement at a high-volume advanced heart failure center. We assessed patients ≥ 18 years who received IABP or Impella support for cardiogenic shock from 1 January 2020 to 31 December 2021. Ninety patients were included, 59 (65.6%) with IABP and 31 (34.4%) with Impella. Impella was used more frequently in less stable patients, as evidenced by higher inotrope scores, greater ventilator support, and worse renal function. While patients on Impella support had higher in-hospital mortality, despite the worse cardiogenic shock in patients for whom clinicians chose Impella support, over 75% were successfully stabilized to recovery or transplantation. Clinicians elect Impella support over IABP for less stable patients, though a high proportion are successfully stabilized. These findings demonstrate the heterogeneity of the cardiogenic shock patient population and may inform future trials to assess the role of different tMCS devices.
Collapse
Affiliation(s)
- Michael Abiragi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Tahli Singer-Englar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Robert M. Cole
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jaime Moriguchi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jon A. Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence: ; Tel.: +1-310-248-8300
| |
Collapse
|
9
|
Hill MA, Kwon JH, Shorbaji K, Kilic A. Waitlist and transplant outcomes for patients bridged to heart transplantation with Impella 5.0 and 5.5 devices. J Card Surg 2022; 37:5081-5089. [PMID: 36378877 DOI: 10.1111/jocs.17209] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/16/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Impella devices are increasingly utilized as a bridge to heart transplantation (BTT) and are now prioritized as Status 2 under the current heart allocation policy. This study evaluated waitlist and post-transplant outcomes of patients supported with Impella 5.0/5.5 devices. METHODS The United Network of Organ Sharing registry was used to identify adults waitlisted or transplanted with Impella 5.0 or 5.5 devices from 2010 to 2021. Separate analyses were performed for waitlist and transplantation outcomes for patients supported by Impella 5.0/5.5 devices. Competing outcomes for the waitlist analysis included rates of transplantation, recovery, and death or clinical deterioration. Among patients undergoing transplantation, the primary outcome was 1-year survival. Secondary outcomes included rates of rejection, new postoperative dialysis, stroke, and pacemaker implantation after transplantation. RESULTS There were 344 patients waitlisted and 394 patients transplanted with an Impella 5.0 (n = 212 and 251) or 5.5 (n = 132 and 143) device. Competing risk regression demonstrated similar likelihood of transplant (subhazard ratio [SHR], 1.33 (0.98-1.81, p = 0.067)) and similar likelihood of death or clinical deterioration (SHR, 0.67 [0.27-1.69, p = 0.400]) for Impella 5.5 patients. In the transplanted cohort, unadjusted 1-year post-transplant survival was comparable at 91.3% versus 94.6% (log-rank p = 0.661) for patients supported by Impella 5.0 or 5.5 device, respectively, a finding that persisted after risk-adjustment (HR 1.22, p = 0.699). Post-transplant complication rates were also comparable between 5.0 and 5.5 patients. CONCLUSIONS Impella devices can be used as a BTT with excellent survival and minimal post-transplant morbidity. Outcomes were comparable for Impella 5.0 and 5.5 devices.
Collapse
Affiliation(s)
- Morgan A Hill
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
10
|
González LS, Grady M. Intra-aortic balloon pump counterpulsation: technical function, management, and clinical indications. Int Anesthesiol Clin 2022; 60:16-23. [PMID: 35975922 DOI: 10.1097/aia.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Laura S González
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | |
Collapse
|
11
|
Cornwell WK, Pal JD. What's Old Is New Again. Ann Thorac Surg 2022; 114:167. [PMID: 34450177 DOI: 10.1016/j.athoracsur.2021.07.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022]
Affiliation(s)
- William K Cornwell
- Anschutz Medical Campus, University of Colorado, 12631 E 17th Ave, MSC310, Aurora, CO 80045
| | - Jay D Pal
- Anschutz Medical Campus, University of Colorado, 12631 E 17th Ave, MSC310, Aurora, CO 80045.
| |
Collapse
|
12
|
Pahwa S, Dunbar-Matos C, Slaughter MS, Trivedi JR. Use of Impella in Patients Listed for Heart Transplantation. ASAIO J 2022; 68:786-790. [PMID: 35184091 DOI: 10.1097/mat.0000000000001679] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.
Collapse
Affiliation(s)
- Siddharth Pahwa
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | | | - Mark S Slaughter
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Jaimin R Trivedi
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| |
Collapse
|
13
|
Morici N, Marini C, Sacco A, Tavazzi G, Saia F, Palazzini M, Oliva F, De Ferrari GM, Colombo PC, Kapur NK, Garan AR, Pappalardo F. Intra-aortic balloon pump for acute-on-chronic heart failure complicated by cardiogenic shock. J Card Fail 2021; 28:1202-1216. [PMID: 34774745 DOI: 10.1016/j.cardfail.2021.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 12/22/2022]
Abstract
The Intra-aortic balloon pump (IABP) is widely implanted as temporary mechanical circulatory support for cardiogenic shock (CS). However, its use is declining following the results of the IABP-SHOCK II trial, which failed to show a clinical benefit of IABP in acute coronary syndrome (ACS) related CS. Acute-on-chronic heart failure has become an increasingly recognized, distinct etiology of CS (HF-CS). The pathophysiology of HF-CS differs from ACS-CS, as it typically represents the progression from a state of congestion (with relatively preserved cardiac output) to a low output state with hypoperfusion. The IABP is a "volume displacement pump" that promotes forward flow from a high-capacitance reservoir to low-capacitance vessels, improving peripheral perfusion and decreasing left ventricular afterload in the setting of high filling pressures. The IABP can improve ventricular-vascular coupling and, therefore, myocardial energetics. Additionally, many HF-CS patients are candidates for cardiac replacement therapies (left ventricular assist device or heart transplantation), and, therefore, may benefit from a "bridge" strategy that stabilizes the hemodynamics and end-organ function in preparation for more durable therapies. Notably, the new United Network for Organ Sharing donor heart allocation system has recently prioritized patients on IABP support. This review describes the role of IABP for the treatment of HF-CS. It also briefly discusses new strategies for vascular access as well as a fully implantable versions for a longer duration of support.
Collapse
Affiliation(s)
- Nuccia Morici
- Cardiac Intensive Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy..
| | - Claudia Marini
- S.C. Cardiologia, Polo San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Alice Sacco
- Cardiac Intensive Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia Italy; Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, Pavia, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Matteo Palazzini
- Cardiac Intensive Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, Università degli Studi Milano-Bicocca, Milan, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Fabrizio Oliva
- Cardiac Intensive Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Gaetano Maria De Ferrari
- Dept of Cardiology OU Città della Salute e della Scienza di Torino, Dept of Medical Sciences, University of Torino, Torino, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian, NewYork, USA; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Navin K Kapur
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, USA; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Arthur Reshad Garan
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Federico Pappalardo
- School of Medicine and Surgery, Università degli Studi Milano-Bicocca, Milan, Italy; Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| |
Collapse
|