Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery

Current insights on temporary mechanical circulatory support in adults with post-cardiotomy cardiogenic shock

Post-cardiotomy cardiogenic shock (PCCS) is a critical condition characterized by persistent low cardiac output syndrome (LCOS) that manifests either as an inability to wean from cardiopulmonary bypass (CPB) or as severe cardiac dysfunction in the immediate post-operative period despite optimal medical therapy. With an incidence of 2-20%, PCCS is associated with high morbidity, mortality, and healthcare resource utilization. This review explores the pathophysiology of PCCS while emphasizing mechanisms such as direct myocardial damage, ischaemia-reperfusion injury, and systemic effects of extracorporeal circulation. It also discusses key diagnostic tools for PCCS including echocardiography, pulmonary artery catheters, vasoactive inotropic scores (VIS), and lactate clearance, which facilitate early recognition and management. Treatment pathways centred on temporary mechanical circulatory support (tMCS), tailored to clinical scenarios such as the inability to wean from CPB or refractory LCOS. The pivotal role of the multi-disciplinary Heart Team in decision-making, collaboration, and patient-centred care is highlighted. Finally, weaning protocols and considerations for long-term outcomes are discussed, underscoring the need for timely interventions and a personalized approach. Advances in PCCS management continue to evolve, aiming to improve survival and long-term outcomes for this high-risk population.

Trajectories following Impella 5.5 support are associated with initial presentation acuity

BACKGROUND

Impella 5.5 is a temporary left ventricular assist device utilized to support patients with cardiogenic shock and those undergoing high-risk cardiac interventions.

METHODS

From October 2019 to January 2023, 226 patients received Impella 5.5 support at Cleveland Clinic main campus. Patients were stratified by Society for Cardiovascular Angiography and Interventions (SCAI) shock stages. Immediate post-Impella 5.5 trajectories were compared across groups. Trajectories were defined as mortality on Impella 5.5, transition to advanced heart failure therapies (durable left ventricular assist device/heart transplantation), or survival to Impella 5.5 removal without advanced therapies.

RESULTS

Overall, 148 (65%) patients with cardiogenic shock and 78 (35%) undergoing high-risk cardiac interventions received Impella 5.5 support. SCAI stage was A in 63 (28%), B in 10 (4.4%), C in 29 (13%), D in 104 (46%), and E in 20 (8.8%). Mortality on Impella 5.5 was highest in SCAI stage E (A: 3.2%, B: 10%, C: 14%, D: 27%, E: 35%; p < 0.01). Transition to advanced therapies (durable left ventricular assist device or heart transplantation) was highest in SCAI stages C-D (A: 1.6%, B: 0.0%, C: 45%, D: 36%, E: 20%; p < 0.01). Survival to Impella removal without advanced therapies was highest in SCAI stages A-B (A: 95%, B: 90%, C: 41%, D: 38%, E: 45%; p < 0.01).

CONCLUSIONS

Stratification by presentation acuity in candidates for Impella 5.5 insertion may help identify which patients may and may not benefit from this escalation of tailored temporary mechanical circulatory support.

A successful post-surgical treatment of cardiogenic shock using Impella via brachiocephalic artery

Patients with low-flow, low-gradient severe aortic stenosis and ischaemic cardiomyopathy are at risk for postcardiotomy cardiogenic shock and have a poor prognosis. Although Impella has emerged as a bridge therapy, traditional approaches for Impella insertion are infeasible in patients with peripheral vascular diseases. We successfully managed postcardiotomy cardiogenic shock in a patient with low-flow, low-gradient severe aortic stenosis and ischaemic cardiomyopathy and limited vascular access by introducing Impella via the brachiocephalic artery. Impella may enable the surgical treatment of high-risk patients.

Temporary Mechanical Circulatory Support after Cardiac Surgery

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.

Outcomes of Impella 5.0 and 5.5 for cardiogenic shock: A single-center 137 patient experience

BACKGROUND

This study evaluated the outcomes of patients with cardiogenic shock (CS) supported with Impella 5.0 or 5.5 and identified risk factors for in-hospital mortality.

METHODS

Adults with CS who were supported with Impella 5.0 or 5.5 at a single institution were included. Patients were stratified into three groups according to their CS etiology: (1) acute myocardial infarction (AMI), (2) acute decompensated heart failure (ADHF), and (3) postcardiotomy (PC). The primary outcome was survival, and secondary outcomes included adverse events during Impella support and length of stay. Multivariable logistic regression was performed to identify risk factors for in-hospital mortality.

RESULTS

One hundred and thirty-seven patients with CS secondary to AMI (n = 47), ADHF (n = 86), and PC (n = 4) were included. The ADHF group had the highest survival rates at all time points. Acute kidney injury (AKI) was the most common complication during Impella support in all 3 groups. Increased rates of AKI and de novo renal replacement therapy were observed in the PC group, and the AMI group experienced a higher incidence of bleeding requiring transfusion. Multivariable analysis demonstrated diabetes mellitus, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine were independent predictors of in-hospital mortality, but the etiology of CS did not impact mortality.

CONCLUSIONS

This study demonstrates that Impella 5.0 and 5.5 provide effective mechanical support for patients with CS with favorable outcomes, with nearly two-thirds of patients alive at 180 days. Diabetes, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine are strong risk factors for in-hospital mortality.