Clinical Research & Data, Echocardiography, ECMO, Femoral Access, Insertion, Safety & Efficacy, AMI Cardiogenic Shock
ICU Bedside Impella® Insertion in Cardiogenic Shock
Federico Pappalardo, MD discusses his recently published paper, “Bedside insertion of Impella® percutaneous ventricular assist device in patients with cardiogenic shock” published with Dr. Marina Pieri in International Journal of Cardiology. Dr. Pappalardo is an intensivist and heart failure specialist affiliated with ISMETT UPMC hospital in Palermo, Italy.
This paper is a retrospective study comparing characteristics and outcomes in patients undergoing insertion of the Impella® heart pump under transesophageal echocardiography (TEE) at the bedside in the ICU with Impella insertion under fluoroscopic guidance in the cath lab. The authors conclude that emergent Impella insertion with TEE guidance is feasible, safe, and effective in critically ill patients with cardiogenic shock.
Dr. Pappalardo explains that many of today’s critical care cardiologists and intensivists can safely manage vascular groin access and have experience performing transesophageal echocardiography. He undertook the study because timing is critical in patients with cardiogenic shock and he saw an opportunity to improve patient outcomes by implanting mechanical circulatory support devices more quickly. As long as it is safe for the patient, he explains, “if we can avoid overlapping our clinical needs with those of the cath labs and ORs, that makes a lot of sense in terms of efficiency of the program and optimization of the logistics of the hospital.”
In this interview with Seth Bilazarian, MD, Dr. Pappalardo acknowledges some of the challenges seen in the data and the importance of a highly skilled team that understands Impella implantation and echocardiography. He also discusses some of the logistics of working with Impella at the ICU bedside and implanting an Impella in a patient who is already on ECMO.
The results of this study included a 100% success rate on Impella insertion and very low complication rates that were similar between the fluoroscopy and TTE groups. While patients in the TEE group had a higher incidence of hemodynamic collapse, V-A ECMO, and higher mortality, Dr. Pappalardo emphasizes that in this patient population, “mortality rate is definitely related to the severity of cardiogenic shock, and therefore it’s not the device per se, but it’s the shock which is driving the need for a specific device and therefore, which is the driver for mortality.”
“If you are surviving, of course you will be at risk of developing complications,” states Dr. Pappalardo. “The ECpella™ approach has been shown to be significantly better in terms of survival, but then when you look through the lines you see that there are more complications. This is not a problem.”
When asked how physicians can improve their skills through continuing education and training so that they can begin thinking about using this option for their own patients, Dr. Pappalardo replied, “My credo is, when you approach the femoral artery, puncture the femoral artery as (if) it is an Impella or an ECMO cannulation, even if you are just putting (in) an A-line for monitoring. Because this is the best way to have a learning process in order to then upgrade your skill to large bore cannulation. And last, but not least, that approach will be used by the operator who will eventually be in the need for putting (in) an MCS device. And when you have done 50 femoral artery cannulations as such, I think that you have completely changed your approach to the groin and it will be completely different in terms of patient safety for proceeding to Impella implantation.”