Patient Management, Surgical Applications
Optimizing Outcomes with Impella 5.5® with SmartAssist®
Transplant cardiologist Rohan Goswami, MD, discusses advances in bridge to decision (BTD) therapy and optimizing outcomes with Impella 5.5 with SmartAssist. Joining him are Jacob Schroder, MD, from Duke University School of Medicine, Dominic Emerson, MD, from Cedars-Sinai Medical Center, and Basar Sareyyupoglu, MD, from the Mayo Clinic in Jacksonville, FL. This presentation was part of the 2021 virtual International Society for Heart & Lung Transplantation (ISHLT) conference.
Dr. Goswami begins by discussing the evolution and role of bridge therapy. “One thing that we recognize in the field is that optimization prior to heart transplantation really improves outcomes, reduces post-operative complications,” Dr. Goswami explains, noting that this talk should help viewers understand how to do that effectively.
He reviews current BTD therapy options and discusses assessing when and how to bridge patients. “The important thing when we’re assessing patients is to think about their current state, where they’re going, and what their long-term outcomes would be with the therapies that we apply.”
Dr. Goswami then presents some real world BTD therapy cases. In thinking about BTD support, he notes, “When we think about what that support does, we have to really think about not just the metabolic profile or the cardiac profile, but really this concept of the cardiometabolic physiology that underpins progressive decompensated heart failure. And I think Impella 5.5 allows us to really decide what to do with the patient during that timeframe.”
He then describes what’s happening in the patient’s body with increased systemic afterload and how Impella 5.5. mitigates that, emphasizing, “I think that the concept of RV afterload optimization by utilizing a left sided device is something that’s really missed in a lot of centers, mainly because I think we’re always worried about supporting the left ventricle. We’re always worried about cardiac output, and I think cardiac output and flow may not be synonymous.” The Impella 5.5 with SmartAssist, he explains, enables optimization of left ventricular kinetics, improves flow, and decreases right ventricular afterload.
Dr. Goswami reviews the current experience with the Impella 5.5 with SmartAssist at his institution, highlighting 100% survival to transplant in 18 patients with Impella 5.5 as BTD compared to 78% survival to transplant in 28 patients with LVAD as bridge to transplant. In addition, median time on waitlist was significantly shorter, 35 days, in the Impella 5.5 cohort compared to 751 days for LVAD patients.
“Supporting patient to surgery allows the surgeons to have an improved surgical environment,” Dr. Goswami explains, noting a significant different between the Impella 5.5 and LVAD cohort in terms of cardiopulmonary bypass time at the time of heart transplantation (181 minutes versus 225 minutes, respectively). He also describes significantly lower vasoactive inotrope scores in the Impella 5.5 cohort compared to LVAD cohort (7.9 versus 13, respectively) and shorter median ICU length of stay and median hospital length of stay in the Impella 5.5. cohort as well.
In the ensuing panel discussion, Dr. Shroder echoes what Dr. Goswami presened. “What I’ll say about our experiences is that it’s been equally good… we’ve seen exactly the same results.” While noting that Duke Medical Center was rather “late to the game” due to cost considerations with the Impella 5.5 with SmartAssist, he explains, “but if you save time on the waitlist, where most of these patients are in the hospital, and if you save time post-operatively, that’s actually a money-saving device rather than money wasting… their post-operative ICU stays are shorter and their length of hospital stays are also shorter.”
Similarly, Dr. Emerson explains, “We’ve had really good results with the way we’ve utilized Impella® as a bridge to decision.” He notes that with the Impella 5.5, “we’ve found that unloading the right heart by allowing those left blood pressures to come down has really improved the kidneys in a lot of cases, and just getting better blood flow and so we’ve seen these patients really turn a corner sometimes.” In addition, he emphasizes, “I’d rather take out Impella any day of the week than do an LVAD explant.”
As a surgeon who works with Dr. Goswami, Dr. Sareyyupoglu emphasizes that the small incisions with the Impella devices “make a huge difference” and the inflammatory issues with insertion and removal of Impella devices are “really, really insignificant” compared to LVADs. “I think this makes a big difference how well these patients recover following transplant operations.”