CARC2: Novel use of newer intravascular ambulatory left ventricular assist devices as a bridging strategy for cardiogenic shock

Background: Cardiogenic shock [CS], either de novo or post-cardiotomy [PCCS] is associated with high mortality. Suitable patients maybe successfully bridged using newer intravascular ambulatory left ventricular assist devices [Impella 5.5, Abiomed, Danvers, MA] as a bridge to recovery or definitive therapy. We compared our outcomes in three categories of patients bridged with Impella 5.5. Methods: Between January 2020 and June 2022, 73 patients underwent trans-axillary artery placement of LV Impella 5.5 for CS/PCCS: Group 1: bridge to durable Left ventricular assist device [LVAD; n=17], group 2: bridge to recovery from PCCS [n=33], group 3: bridge to heart transplant [n=23]. Data were prospectively collected and retrospectively reviewed, and reported as means +/- standard deviations or medians +/-interquartile ranges. Actuarial survival was plotted by the Kaplan Meier method, using the log-rank test for differences between groups. Results: Mean age was 60±13 years; group 1: 58±12 years; group 2: 65±12 years; group 3: 54±13 years [p=0.008]. 14 patients required percutaneous dual-lumen cannula right VAD [RVAD] support: group 1: 4, group 2: 10 [p=0.011]. 16 PCCS patients were transitioned from Extracorporeal membrane oxygenator support [ECMO] to Impella 5.5 to facilitate ambulation and rehabilitation prior to definitive therapy. Duration of Impella support was 15±17 days [p>0.05 between groups]. Complications included device malfunction requiring change [n=5], axillary hematoma requiring re-exploration [n=6], gastrointestinal [GI] bleed [n=8], CVA [n=8], heparin induced thrombocytopenia [n=4], and renal replacement therapies [n=16]. Duration of stay on intensive care unit was 30±32 days [p>0.05 between groups]. Patients were followed for 253±460 days, and 16 deaths occurred: 2 transplant, 4 LVAD, 10 PCCS. Causes of death were GI bleed [n=2], GI ischemia [n=2], RV/BIV failure [n=12]. Kaplan Meier survival was 72±7% in the entire cohort: group 1: 74±11%; group 2: 52±16%; group 3: 91±6%, with a trend for the best survival in transplant group and lower survival in the PCCS group [p=0.07] [figure-1] Conclusions: Our cohort includes a diverse patient population undergoing newer intravascular ambulatory LVAD Impella 5.5 placement and demonstrates low rate of adverse events combined with good survival benefit. Utilization of Impella 5.5 in PCCS, and pre-LVAD placement, combined with percutaneous RVAD, can facilitate weaning from ECMO or even avoid postoperative ECMO completely, with its inherent problems of immobility, bleeding, infections, muscle wasting. This strategy allows for more aggressive and high-risk cardiac surgery. Furthermore, in the transplant cohort, in addition to excellent survival, it has greatly facilitated early ambulation and rehabilitation while awaiting a suitable organ. Figure showing survival by groups: Group 1: LVAD; Group 2: PCCS; Group 3: heart transplant