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Mechanical circulatory support with Impella versus intra-aortic balloon pump or medical treatment in cardiogenic shock-a critical appraisal of current data


Wernly, Bernhard; Seelmaier, Clemens; Leistner, David; Stähli, Barbara E; Pretsch, Ingrid; Lichtenauer, Michael; Jung, Christian; Hoppe, Uta C; Landmesser, Ulf; Thiele, Holger; Lauten, Alexander (2019). Mechanical circulatory support with Impella versus intra-aortic balloon pump or medical treatment in cardiogenic shock-a critical appraisal of current data. Clinical Research in Cardiology, 108(11):1249-1257.

Abstract

AIMS

Patients suffering from cardiogenic shock (CS) have a high mortality and morbidity. The Impella percutaneous left-ventricular assist device (LVAD) decreases LV preload, increases cardiac output, and improves coronary blood flow. We aimed to review and meta-analyze available data comparing Impella versus intra-aortic pump (IABP) counterpulsation or medical treatment in CS due to acute myocardial infarction or post-cardiac arrest.

METHODS AND RESULTS

Study-level data were analyzed. Heterogeneity was assessed using the I$^{2}$ statistic. Risk rates were calculated and obtained using a random-effects model (DerSimonian and Laird). Four studies were found suitable for the final analysis, including 588 patients. Primary endpoint was short-term mortality (in-hospital or 30-day mortality). In a meta-analysis of four studies comparing Impella versus control, Impella was not associated with improved short-term mortality (in-hospital or 30-day mortality; RR 0.84; 95% CI 0.57-1.24; p = 0.38; I$^{2}$ 55%). Stroke risk was not increased (RR 1.00; 95% CI 0.36-2.81; p = 1.00; I$^{2}$2 0%), but risk for major bleeding (RR 3.11 95% CI 1.50-6.44; p = 0.002; I$^{2}$ 0%) and peripheral ischemia complications (RR 2.58; 95% CI 1.24-5.34; p = 0.01; I$^{2}$ 0%) were increased in the Impella group.

CONCLUSION

In patients suffering from severe CS due to AMI, the use of Impella is not associated with improved short-time survival but with higher complications rates compared to IABP and medical treatment. Better patient selection avoiding Impella implantation in futile situations or in possible lower risk CS might be necessary to elucidate possible advantages of Impella in future studies.

Abstract

AIMS

Patients suffering from cardiogenic shock (CS) have a high mortality and morbidity. The Impella percutaneous left-ventricular assist device (LVAD) decreases LV preload, increases cardiac output, and improves coronary blood flow. We aimed to review and meta-analyze available data comparing Impella versus intra-aortic pump (IABP) counterpulsation or medical treatment in CS due to acute myocardial infarction or post-cardiac arrest.

METHODS AND RESULTS

Study-level data were analyzed. Heterogeneity was assessed using the I$^{2}$ statistic. Risk rates were calculated and obtained using a random-effects model (DerSimonian and Laird). Four studies were found suitable for the final analysis, including 588 patients. Primary endpoint was short-term mortality (in-hospital or 30-day mortality). In a meta-analysis of four studies comparing Impella versus control, Impella was not associated with improved short-term mortality (in-hospital or 30-day mortality; RR 0.84; 95% CI 0.57-1.24; p = 0.38; I$^{2}$ 55%). Stroke risk was not increased (RR 1.00; 95% CI 0.36-2.81; p = 1.00; I$^{2}$2 0%), but risk for major bleeding (RR 3.11 95% CI 1.50-6.44; p = 0.002; I$^{2}$ 0%) and peripheral ischemia complications (RR 2.58; 95% CI 1.24-5.34; p = 0.01; I$^{2}$ 0%) were increased in the Impella group.

CONCLUSION

In patients suffering from severe CS due to AMI, the use of Impella is not associated with improved short-time survival but with higher complications rates compared to IABP and medical treatment. Better patient selection avoiding Impella implantation in futile situations or in possible lower risk CS might be necessary to elucidate possible advantages of Impella in future studies.

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Additional indexing

Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Cardiology
Dewey Decimal Classification:610 Medicine & health
Language:English
Date:November 2019
Deposited On:18 Feb 2020 09:12
Last Modified:18 Feb 2020 09:13
Publisher:Springer
ISSN:1861-0684
OA Status:Closed
Publisher DOI:https://doi.org/10.1007/s00392-019-01458-2
PubMed ID:30900010

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