Budget Impact Associated with the Introduction of the Impella 5.0® Mechanical Circulatory Support Device for Cardiogenic Shock in France

In-hospital outcomes of percutaneous left ventricular assist device recipients in cardiogenic shock hospitalizations with chronic kidney disease: A nationwide analysis

BACKGROUND

There is a lack of data on the role of chronic kidney disease (CKD) in patients who received percutaneous left ventricular assist devices (pLVAD) as mechanical circulatory support (MCS) as an adjunct treatment for cardiogenic shock (CS) management.

METHODS

Using National Inpatient Sample (2016-19), we extracted CS patients receiving pLVAD and divided them into CKD and non-CKD cohorts. Multivariate regression analysis was used for adjusted odds ratios for outcomes before and after entropy balancing (EB) and predictive margins for the probability of all-cause in-hospital mortality (ACM). ACM was also compared between CS patients who did not receive MCS.

RESULTS

In our study, 29,515 patients received pLVAD as the only MCS device in CS, and the prevalence of CKD amongst them was 9.7 %. After EB, ACM did not differ in CS with and without CKD (aOR 1.008, p = 0.953). Higher adjusted incidence rate ratios (IRR) were noted for length of stay (LOS) (aOR 1.68, p < 0.001) and hospitalization cost (aOR 1.365, p = 0.001) in CS with CKD. Mean LOS and hospitalization cost was significantly higher in CKD cohort before and after EB (post-EB: 17.4 days vs. 10.3 days, p < 0.001 and USD 652097 vs. 482359, p = 0.001, respectively). ACM was significantly higher in CS patients who did not receive any MCS if they had CKD (aOR 1.26, p < 0.001).

CONCLUSION

CKD patients receiving pLVAD for CS had no difference in ACM but had higher resource utilization than those without CKD. pLVAD use was associated with a lower ACM in CKD patients when compared to patients who did not receive any MCS.

Comparison of in-hospital outcomes of ST-elevation myocardial infarction patients with cardiogenic shock receiving left ventricular mechanical circulatory support devices based on transfer status

BACKGROUND

We aimed to compare outcomes in patients who receive on-site left ventricular mechanical support versus those transferred to other facilities for mechanical support in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock.

METHODS

This retrospective study analyzed data from the 2016 to 2020 Nationwide Inpatient Sample (NIS) database. We identified patients with STEMI and cardiogenic shock who received Impella and LVAD placement during their hospital stay. They were divided into two groups: those with in-house (direct) placement and those transferred to higher-level medical centers. The primary goal was to compare mortality rates between these groups.

RESULTS

During the study, 15,934 (75.2%) received in-house left ventricular support, while 5255 (24.8%) were transferred. Mean age (63 vs. 64 years) and female percentage (25 vs. 26%) were similar. The average time from admission to receiving LV support was 0.8 days for direct group versus 2.8 days for transfer group (p < 0.001). Transferred patients had a higher rate of prior heart failure (68 vs. 79%, p < 0.001) and peripheral vascular disease (10 vs. 14%, p < 0.001) but a lower rate of hypertension (23 vs. 17%, p = 0.003). There were no significant differences in other comorbidities. Primary outcome mortality did not significantly differ (44.9 vs. 44.2, p = 0.66). After multivariate analysis, transferred patients had higher rates of ECMO usage, acute kidney injury, renal replacement therapy, major bleeding, and ischemic stroke. Length of stay (8 vs. 15 days, p < 0.001) and total charges ($391,472 vs. $581,183, p < 0.001) were significantly higher in the transferred group.

CONCLUSION

Among STEMI patients with cardiogenic shock, our study found no significant difference in mortality between patients transferred for and those with on-site LV support. Those transferred patients experienced more complications, longer length of stay, and increased hospital costs.

An in silico analysis of unsteady flow structures in a microaxial blood pump under a pulsating rotation speed

BACKGROUND AND OBJECTIVE

Ventricular assist devices (VADs) are generally designed to perform continuous flow. However, it has been proven that continuous flow, which is not a physiological hemodynamic state, may cause severe complications such as gastrointestinal bleeding, pulmonary hypertension, and ventricular suction. For these reasons, many pulsating blood pump control strategies have been proposed and have the potential for application in percutaneous ventricular assist devices (pVADs) or microaxial blood pumps. A few cases report extra hemolysis when introducing pulsating speed, while none involve blood pumps. This research's primary purpose is to evaluate the potential hemolysis of pVAD under pulsating flow conditions.

METHODS

First, the pulsating flow state is deduced using a heart failure model and varying speed. The heart model is established according to the pathology state collected from a clinical check. The rotation speed and boundary physical state are set to fit the heart failure model. The computational fluid dynamics (CFD) method with the hemolysis prediction model is performed. Furthermore, we used proper orthogonal decomposition (POD) analysis to reconstruct the flow field and obtain more details about shearing and transporting effects.

RESULTS

(1) As a variable rotational speed was introduced, no significant gain in hemolysis accumulation appeared in pVAD. This is quite different from long-term implantable VADs. (2) Pulsation affects hemolysis mainly through pressure (or normal stress). Variable rotational speed affects hemolysis mainly through flow instability. (3) Variable rotational speed will increase the instability and influence hemolysis by transporting and shearing effects, while the transporting effect is more significant.

CONCLUSIONS

The unsteady flow state will affect the spatial distribution of hemolysis, which should be taken into account during control strategy and impeller shape design.

Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock

The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.

Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy

INTRODUCTION

Trans-valvular micro-axial flow pumps such as Impella are increasingly utilized in patients with cardiogenic shock [CS]. A number of different Impella devices are now available providing a wide range of cardiac output. Among these, the Impella 5.0 and recently introduced Impella 5.5 pumps can provides 5.55 L/min of flow, enabling complete left ventricular support with more favorable hemodynamic effects on myocardial oxygen consumption and left ventricular unloading. These devices require placement of a surgical conduit graft for endovascular delivery, but are increasingly being used in patients with CS due to acutely decompensated heart failure [ADHF], acute myocardial infarction [AMI] and after cardiac surgery as a bridge to transplant or durable ventricular assist device surgery or myocardial recovery.

AREAS COVERED

This review focuses on the device profile and use of the Impella 5.0 and 5.5 systems in patients with CS. Specifically; we reviewed the published literature for Impella 5.0 device to summarize data regarding safety and efficacy.

EXPERT OPINION

The Impella 5.0 and 5.5 are trans-valvular micro-axial flow pumps for which the current data suggest excellent safety and efficacy profiles as approaches to provide circulatory support, myocardial unloading, and axillary placement enabling patient mobilization and rehabilitation.

ABBREVIATIONS

pMCS, Percutaneous mechanical circulatory support devices; CS, Cardiogenic shock; ADHF, Acute decompensated heart failure; AMI, Acute myocardial infarction; LVAD, Left ventricular assist deviceI; ABP, Intra-aortic balloon pump; VA-ECLS, Veno-arterial extracorporeal life support.