106. ECMO and Impella in Cardiogenic Shock: Choosing the Right Mechanical Circulatory Support to Improve Clinical Outcomes

Objective: To evaluate the outcomes of patients supported with temporary mechanical circulatory support (MCS) in patients with cardiogenic shock and assess the impact of a decision algorithm as a tool for outcomes improvement.
Methods: Patients implanted with temporary MCS for cardiogenic shock locally between January 2010 and December 2020, and who were supported by either an Impella (CP and 5.0) or VA-ECMO were reviewed. Patients with postcardiotomy shock or out-of-hospital cardiac arrest were excluded. A local decision algorithm recommends Impella in cardiogenic shock with isolated left ventricular failure and ECMO in cases of biventricular or multi-organ failure. The clinical outcomes of patients who were managed according to the decision algorithm (Per protocol: PP group) with those who didn't (Off-protocol: OP group) were compared.
Results: Among the 75 patients included, 15 (20%) were in the OP group, with 11 patients being supported with Impella instead of VA-ECMO, and 4 patients being supported with VA-ECMO instead of Impella. In the OP group, patients tend to be older (58±10 vs. 51±13, p=0.06), but with less severe disease, as demonstrated by less frequent biventricular failure (13% vs 59%, p=0.001), lower bilirubin level (16±12 vs 30±33, p=0.04) and a higher proportion of patients in SCAI stage D (60% vs 32%, p=0.04) compared to stage E (27% vs 52%, p=0.08). Other baseline characteristics were comparable between the two groups. The rates of successful weaning (33% vs 40%, p=62), 30-day survival (47% vs 55%, p=0.58), and discharged home at 30 days (27% vs 32%, p=0.71) were similar between the groups. According to adherence to the decision algorithm (OP group), patients who received an Impella instead of an ECMO had significantly worse outcomes (Successful weaning: 9 vs 62%, p=0.01 and 30-day survival: 23 vs 77%, p=0.04, for OP and PP groups respectively). By contrast, the four patients in the OP group who initially received a VA-ECMO instead of an Impella were all alive at 30 days.
Conclusions: In cardiogenic shock, adherence to a decision algorithm for temporary MCS selection (Impella in case of isolated left ventricular failure and ECMO for biventricular or multi-organ failure) is associated with improved outcomes. Only deviation from protocol using an Impella instead of ECMO is associated with dismal outcomes. Our simple algorithm can help direct shock teams towards support strategies for optimal outcomes.

Olina Dagher (1), Pierre-Emmanuel Noly (1), Mark Liszkowski (1), Anique Ducharme (1), Philippe Demers (1), Yoan Lamarche (1), (1) Montreal Heart Institute, Montréal, Quebec

M. Faraz Masood

Invited Discussant

I am an Associate Professor of Surgery in Division of Cardiothoracic Surgery at Wasington University of St. Louis.  I am a cardiothoracic surgeon with focused training and practice of Advanced Surgical Treatment of Heart Failure.  My practice at our large volume, quaternary referral center involves surgical and peri operative care of Orthotopic Heart Transplantation (OHT), Durable Mechanical Circulatory Support; Left Ventricular Assist Devices (LVADs), and Temporary Mechanical Support; with Extra Corporeal Life Support (ECMO) Devices.  Additionally, I serve as the Chief of Cardiac Surgery at John Cochram VA Medical Center.  I have been involved with implantation of >320 LVADs, >500 ECLS devices, and 170 OHTs, and this clinical volume brings robust clinical and research activities.  My academic activities encompass clinical science of patients with critical illness and advanced heart failure.  I am PI, or co-investigator of several multi-center studies of patients undergoing advanced surgical treatment of heart failure.  My academic focus has been on surgical therapies of heart failure.  The published outcomes based research work has encompased topics on heart transplantation, ventricular assist devices and ECMO.

Olina Dagher

Abstract Presenter

Cumming School of Medicine

Specialties: Adult Cardiac, Perioperative Management/Critical Care, Treatment/Procedure/Operation/Surgery, Critical Care, Electrophysiology--Arrhythmias, Critical care, Mechanical Circulatory Assistance, ECMO