Combined Hemodynamic Support With the Impella 2.5 Device and Intra-Aortic Balloon Pump for Management of Refractory Cardiogenic Shock

ABSTRACT: Cardiogenic shock (CS) during elective percutaneous coronary intervention (PCI) is a rare but potentially lethal clinical condition. Pharmacological inotropic support and mechanical circulatory assistance with intra-aortic balloon pump (IABP) counterpulsation remains the gold-standard treatment. We report the case of a patient who developed refractory CS during elective PCI and was successfully managed with concomitant use of IABP and the Impella 2.5 L support device. 

J INVASIVE CARDIOL 2014;26(5):E50-E51

Key words: intra-aortic balloon pump, cardiogenic shock

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Case Report. A 63-year-old female patient presented to the outpatient clinic complaining of a 6-month history of worsening effort angina (Canadian Cardiovascular Society grade III). She had multiple risk factors for coronary artery disease (CAD), including hypertension, hypercholesterolemia, and insulin-dependent diabetes mellitus, as well as multiple other comorbidities, such as stage-IV chronic kidney disease, diabetic retinopathy and neuropathy, iron deficiency anemia, and poor mobility secondary to severe rheumatoid arthritis affecting her knees and ankles. Laboratory investigations showed serum creatinine of 270 µmol/L (3.05 mg/dL), estimated glomerular filtration rate (eGFR) of 16 mL/min/1.73 m², and hemoglobin of 10.1 g/dL. Elective coronary angiography demonstrated diffuse disease of the left anterior descending (LAD) artery, with involvement of the diagonal branches, and severe proximal disease of the left circumflex (LCX) artery, with ostial involvement (Videos 1 and 2). The right coronary artery (RCA) had diffuse atheroma, but no flow-limiting lesions. Transthoracic echocardiography depicted left ventricular (LV) hypertrophy with normal systolic and valvular function. The case was discussed at the weekly Heart Team meeting; in view of the patient’s high surgical risk, a staged percutaneous coronary intervention (PCI) approach was decided.

The patient was admitted electively 24 hours prior to the procedure for prehydration and treatment with N-acetylcysteine. A 6 Fr right femoral approach was chosen, and the left coronary artery was engaged with a 6 Fr EBU 3.5 guiding catheter (Medtronic, Inc). The LAD lesion was predilated with a 2.5 x 12 mm Emerge balloon (Boston Scientific) and treated with two overlapping Xience Prime everolimus-eluting stents (Abbott Vascular): 3.0 x 28 mm proximally and 2.75 x 23 mm distally. Following deployment of the proximal stent, there was significant impairment of flow in a small, heavily diseased proximal diagonal and the patient became bradycardic and hypotensive with a mean arterial pressure (MAP) of 40 mm Hg (Video 3). A 40 cc intra-aortic balloon pump (IABP; Maquet Cardiovascular) and a temporary pacing wire were immediately inserted. Bedside echocardiography showed severe anterolateral hypokinesia, but no evidence of a pericardial effusion. No clinical signs suggestive of an anaphylactic reaction were evident. The diagonal was wired and subsequently dilated with a 2.0 x 12 mm Emerge balloon (Boston Scientific). Despite flow restoration, her circulation remained adrenaline dependent (noradrenaline 12 µg/min), with the IABP failing to augment as the pressures fell (Video 4). Thus, we proceeded to treat the LCX. The lesion was prepared with 2.0 x 12 mm balloon predilatation and treated with a 2.5 x 12 mm Xience Prime EES back to the ostium (Video 5). Although TIMI-3 flow was restored in all vessels, the patient remained in refractory cardiogenic shock (MAP, 45 mm Hg), despite concomitant inotropic support and IABP counterpulsation. Digital subtraction angiography excluded any active bleeding from the femoral or iliac vessels. Approximately 30 minutes after her initial hemodynamic collapse, an Impella 2.5 L support device (Impella Cardiosystems) was inserted via 13 Fr left femoral puncture and the flow was titrated up to a maximal support of 2.5 L/min (Video 6). However, the MAP remained low; therefore, the IABP was immediately reactivated with rapid hemodynamic improvement (MAP, ~80 mm Hg) (Video 7). This degree of stability allowed transfer to the intensive care unit with minimal inotropic requirements (noradrenaline, 0.5 µg/min), where she received continuous hemofiltration. Inotropic support was weaned off within a few hours of admission to the intensive care unit, the Impella device was successfully removed 24 hours later, and the patient was weaned from the IABP 36 hours later. After a prolonged gradual recovery, the patient was transferred to her local renal unit for ongoing rehabilitation. Echocardiography on discharge showed normal LV function (Video 8).

Discussion. Cardiogenic shock during elective PCI is a rare, but potentially lethal, clinical condition. Hemodynamic support in this setting involves the use of inotropic and mechanical circulatory support. The use of IABP in patients with cardiogenic shock has been shown to decrease the LV workload, augment the MAP, and enhance coronary blood flow.¹ Moreover, it has been linked to reduced myocardial oxygen demands and decrease of LV wall tension via reduction of the LV end-diastolic volumes and end-diastolic pressures.²

More recently, percutaneous LV assist devices that can be implanted in the catheterization laboratory have been approved for the management of cardiogenic shock. The Impella Recover 2.5 can be inserted via a 13 Fr femoral sheath and is deployed in a retrograde manner across the aortic valve. The Impella 5.0 system can provide up to 5 L/min of circulatory support; however, its insertion requires a surgical cut down. The use of the Impella has been associated with increased aortic pressure and antegrade flow, enhanced coronary perfusion, and increased cardiac output. Several studies have compared the effectiveness of IABP and the Impella device in the management of patients with cardiogenic shock. A recent meta-analysis of these trials suggested that although the use of percutaneous LV assist devices provided superior hemodynamic support, there was no survival benefit compared to the use of IABP.³

There are limited data on the efficacy and safety of the combined use of IABP and the Impella in patients with refractory cardiogenic shock. In an animal study, the addition of the Impella to the IABP resulted in a significant leftward shift of the pressure-volume loop, with increase of the overall cardiac power output, improvement of the LV workload, and enhancement of coronary artery perfusion.⁴ The clinical experience of this approach is based on a few published case reports. Combined circulatory support has previously been reported in 3 patients who presented with an acute myocardial infarction,^5-7 1 patient with acute fulminant myocarditis,⁸ and 1 patient with profound cardiogenic shock secondary to non-ischemic cardiomyopathy.⁹ Although hemodynamic improvement was achieved in all of these cases, 2 of the patients died a few days later due to multiorgan failure.^5,7 In a series of 7 patients with low-output syndrome following open-heart surgery and 6 patients undergoing high-risk PCI, the addition of the Impella device to inotropes and IABP was proven effective, although no benefit was observed in the patients undergoing valve replacement.¹⁰ Although current data are still scarce and further studies are required, dual circulatory support in patients with refractory CS may be a safe and effective approach.

References

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From the ¹Department of Cardiology, St. Thomas’ Hospital and ²Cardiovascular Division, St. Thomas’ Hospital Campus, King’s College London, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted August 21, 2013, provisional acceptance given September 12, 2013, final version accepted September 23, 2013.

Address for correspondence: Antonios N. Pavlidis, Department of Cardiology, St. Thomas’ Hospital, Westminster Bridge Road, London, UK SE1 7EH. Email: antonispav@yahoo.com