(188) The Optimum Patient for Impella LVAD Insertion: Lessons From Two Major Global Registries and a Study

Introduction: Ventricular assist devices like Impella microaxial pump can provide hemodynamic support & improve outcomes in cardiogenic shock. We analyzed the variation in initial outcomes and predictors of mortality in a cohort of cardiogenic shock/arrest patients who were treated with an Impella. We aimed to understand the best practices for initiating Impella support.

Methods: We did comprehensive literature search from 2013 to 2023 across PubMed, Scopus, & Google Scholar using keywords: “myocardial infarction, cardiogenic shock, cardiac arrest, Impella, and ventricular assist devices.” Inclusion criteria were limited to peer-reviewed large-scale registries/studies. We screened titles and abstracts, followed by full-text reviews to assess relevance. Ultimately, we included 3 multi-center registries and a study with total of 838 patients across Japan and 5 European countries. Our study was limited by the fact that only articles in English were included,

Results: Our analysis showed that early insertion ( < 6 hr) & lower lactate levels ( < 3.3 mmo/L)are associated with better outcomes. The studies showed variations in patient outcomes, with the Japanese registry having higher 30-day survival (63.1%) and lower major bleeding complications (10.8%) compared to Euro Shock registry, (35.8% and 28.6%), respectively. In contrast, the PloS One study had a higher mortality rate (81%) and a higher incidence of elevated serum lactate (n= 51 w lactate >3.3mmol/L). The Japanese registry demonstrated a lower incidence of hemolysis (1.8%) compared to the Euro Shock registry (7.5%). In addition, the PloS One study showed a substantially higher incidence of decreased left ventricular ejection fraction (LVEF) (41.6%) compared to the Euro Shock registry (0.27%). Also Impella with VA ECMO support combined have improved survival across all patients with 30 day survival of 68.1%) and in high risk patients with age >66 years & lactate levels >3.3 mmol/L.

Conclusions: Age and lactate levels are essential predictors of mortality, thus, a personalized approach in Impella therapy should be adopted. Initiation of Impella therapy earlier in younger patients but exercising caution in older patients (>66) with higher lactate level >3.3 mmol/L. Further research is needed to provide robust evidence about the use of Impella in such patients.