Impella 5.0 Treatment as a Bridge-to-Decision Option after Extracorporeal Life Support in Patients with Unclear Neurologic Outcome

Objectives: The Impella 5.0 device (Abiomed) seems to be a less invasive but equivalent hemodynamic alternative than venoarterial extracorporeal life support (ECLS) if right ventricular function and lung function allow switching from ECLS to LV support, which allows LV unloading superior to the ECLS. In patients with unclear neurologic situations, ECLS should be discontinued promptly if there is no hope for healthy survival according to ELSO guidelines. However, durable LVAD implantation is contraindicated in patients with unclear neurologic outcome according to the ISHLT recommendations. Impella 5.0 therapy might reduce ECLS-related complications and allows further evaluation of the neurologic situation.

Methods: We retrospectively reviewed 30 patients (mean age: 56.5 ± 10.7 years) who were in need of ECLS and underwent Impella 5.0 implantation after recovery of the right ventricular and pulmonary function with unclear neurological outcome between January 2016 and July 2019. Neurological function was measured by cerebral performance category and a modified ranking scale.

Results: Twenty-six (86.6%) patients received cardiopulmonary resuscitation (CPR) before ECLS implantation. Mean duration of CPR was 67.4 ± 32.3 min. 22 (73.3%) patients suffered from acute myocardial infarction. Mean time on ECLS before Impella 5.0 implantation was 9.3 ± 1.7 days and 18 patients (60.0%) had concomitant Impella 2.5/CP treatment for LV unloading. All patients have been weaned successfully from ECLS and received Impella 5.0 implantation using the axillary artery. Mean time on Impella 5.0 treatment alone was 16.3 ± 4.7 days. Seven patients (23.3%) have been bridged to a durable LVAD. In 10 patients (33.3%), myocardial function recovered and the Impella 5.0 was explanted. 30-day survival was 66.7%. Bleeding complications were reduced by 75% after switch to Impella 5.0. 73.3% of patients were able to be extubated and mobilized after Impella 5.0 implantation. Both quantitative measures of cerebral performance improved significantly after 30 days (p < 0.01).

Conclusion: Impella 5.0 support provides a good bridge-to-decision option for patients after ECLS implantation that have a recovered RV and lung function and leads to LV unloading. It is an ideal solution to avoid ECLS-related complications such as bleeding and limb ischemia. Impella 5.0 therapy allows further evaluation of the neurologic situation and further therapy options after ECLS therapy. Almost two-thirds of these high-risk patients survived with good neurologic outcome.