ECPELLA

[VFlutter]

For those that do ECMO transports, are you seeing an increase in VA ECMO + Impella aka ECPELLA? This seems to becoming a more popular treatment.

One of the biggest problems with VA ECMO is the significantly increased afterload, from retrograde arterial flow, resulting in increased LV wall tension and dilation. Not a huge deal if the ECMO is used as a bridge to device, LVAD, however if the goal is native heart recovery then it needs to be addressed by "venting" the LV. The two most popular options are IABP or Impella. The benefit of IABP are significantly reduced cost and relative simplicity compared to the Impella however the Impella seems to be the most effective.

In practice you will see a VA ECMO patient with an Impella on p1 or p2 providing just enough flow (~ 1 Lpm) to offload the LV. It will likely be alarming due to inability to obtain a placement signal. The patient will be extremely volume dependent and is a constant balancing act between the ECMO, Impella, and native heart flows.

Overall, pretty cool.

https://www.jhltonline.org/article/S1053-2498(16)00970-0/abstract

 

[TXmed]

Ive read and heard of several places doing this. At my current service they seem to prefer the IABP instead of the impella to prevent LV stunning. But then again this is what ive observed on the aircraft, im just a medic and am not in the CVICU

 

[Peak]

The use of impellas (or any other LVAD) and balloon pumps are just driven on what the goal of therapy is. ECMO and impellas don't help with coronary perfusion, which is why balloon pumps are still used so much in the adult world and are actually being used more in peds.

One of the major detriments to impellas (as well as ECMO, some other LVADs, CAVR, and the like) is that they can cause pretty significant hemolysis which don't really see with balloons pumps. As a short bridge to therapy we can certainly manage this with CRRT and transfusions, but it isn't ideal for anything longer than a couple of days. Ideally if we suspect the need for long term aggressive ventricular support a membrane based pump like the berlin heart will support the ventrical, when used as LVAD supports coronary artery perfusion, and does not cause any significant hemolysis.

 

[CANMAN]

We aren’t seeing a huge uptick in impella’s in my region. When they first came out our program felt like they were going to be all the rage. But I felt like a lot of facilities struggled with deployment and correct placement issues and to date I have seen/transported one. This is in the D.C. Metro region, with our main patterns being inbound to both D.C. tertiary cardiac facilities and University of MD and Hopkins. None of the big player referral centers are messing with them around this way. If they’re using them in those tertiary centers then obviously they aren’t being transferred out and like TxMed said I don’t work in a CVICU so I don’t have that exposure to them.