Upfront Impella 5.0 vs. Prior Mechanical Circulatory Support Use in Cardiogenic Shock: A Single Center Experience

Purpose There has been an emphasis on treating cardiogenic shock (CS) with early mechanical circulatory support (MCS). Yet, algorithmic approaches for the use of specific MCS devices is institutionally dependent. We evaluated the impact of early, upfront Impella 5.0 vs. an alternative MCS device prior to Impella 5.0. Methods Retrospective analysis was performed on 28 consecutive patients at a single center between Jan. '19 - Aug. '20 implanted with Impella 5.0. Patients were separated into those receiving upfront Impella 5.0 and those that had a different MCS device prior to Impella 5.0. Clinical outcomes and hemodynamic data were collected at various time points. Results 16 patients (57%) with a mean age of 60 ± 10.2 years received upfront Impella 5.0, while 12 (43%) with a mean age of 58 ± 12.6 years received an alternative MCS device first (6 IABP, 6 Impella CP). Etiologies of CS in the upfront Impella 5.0 group were decompensated heart failure (HF) in 15 patients (94%) and MI in 1 patient (6%), and in the prior MCS group were decompensated HF in 5 patients (42%) and MI in 7 patients (58%). The mean duration of either IABP or Impella CP use before Impella 5.0 was 0.83 days. The upfront Impella 5.0 cohort had a trend towards higher initial filling pressures shown by elevated RAP, mPAP, PCWP, and reduced CI and CPO prior to implantation. Greater improvements were also seen in each of these variables at 72 hours compared to the alternative MCS group (Figure 1). Complications rates were higher in the alternative MCS group with significant hemolysis in the Impella CP arm with an average plasma free hemoglobin of 324 ± 268 mg/dL, and 1 major vascular complication requiring surgical intervention; and 1 ischemic stroke. Survival in the upfront Impella 5.0 group was 87% and only 56% in the alternative MCS group. Conclusion Early use of Impella 5.0 provides more hemodynamic support and may reduce complications and improve outcomes. It should be considered as initial strategy, when feasible, in patients with CS that require use of MCS.