From the Guidelines
Impella placement in patients with hypertrophic obstructive cardiomyopathy (HOCM) and multiple organ dysfunction syndrome (MODS) is not recommended as first-line mechanical circulatory support due to the risk of worsening left ventricular outflow tract obstruction, and alternative devices like VA-ECMO may be preferable initially. In patients with HOCM, the high-velocity suction at the inlet of Impella devices can potentially exacerbate the existing obstruction and cause hemodynamic collapse, as noted in various studies 1. If mechanical support is absolutely necessary in HOCM, careful consideration of the risks and benefits is required. In patients with MODS, Impella can be considered but requires close monitoring of all organ systems, including careful attention to renal function and dose adjustments of medications as needed, as suggested by recent guidelines 1. The typical Impella regimen would include anticoagulation with heparin targeting an ACT of 160-180 seconds, careful positioning verification with echocardiography and fluoroscopy, and starting at P2-P3 setting before titrating based on hemodynamic response, as recommended in the literature 1. Patients should receive aspirin 325mg daily while the device is in place. Impella support in MODS patients should be used as a bridge to recovery or definitive therapy, with daily assessment of organ function to determine the appropriate duration of support, as outlined in recent studies 1. The benefit of Impella in these complex cases is providing cardiac output while reducing myocardial oxygen demand, but this must be balanced against the risks of bleeding, hemolysis, and potential worsening of HOCM obstruction, as highlighted in the most recent and highest quality study 1.
Some key points to consider when using Impella in MODS patients include:
- Close monitoring of all organ systems, including renal function and cardiac output
- Careful positioning verification with echocardiography and fluoroscopy
- Starting at P2-P3 setting before titrating based on hemodynamic response
- Anticoagulation with heparin targeting an ACT of 160-180 seconds
- Aspirin 325mg daily while the device is in place
- Daily assessment of organ function to determine the appropriate duration of support
- Balancing the benefits of Impella against the risks of bleeding, hemolysis, and potential worsening of HOCM obstruction, as noted in the literature 1.
Overall, the use of Impella in patients with HOCM and MODS requires careful consideration of the risks and benefits, and should be guided by the most recent and highest quality evidence, as outlined in the study by 1.
From the Research
Impella Placement in HOCM and MODS
- The use of Impella devices in patients with hypertrophic obstructive cardiomyopathy (HOCM) and cardiogenic shock is a topic of interest, with several studies investigating its efficacy and safety 2, 3, 4, 5.
- A review of contemporary invasive treatment approaches for HOCM highlights the importance of patient selection for procedures such as alcohol septal ablation and surgical myectomy, but does not specifically discuss Impella placement 6.
- Studies comparing Impella use with extracorporeal membranous oxygenation (ECMO) in patients with cardiogenic shock suggest that Impella may be associated with lower in-hospital mortality, stroke, and device-related complications 3, 4, 5.
- However, the evidence for Impella placement in HOCM specifically is limited, and more research is needed to determine its safety and efficacy in this patient population.
- The technical specifications, indications for use, and implantation techniques for Impella devices are outlined in a review of the devices, but do not provide specific guidance on placement in HOCM or MODS patients 2.
Key Findings
- Impella use may be associated with improved survival and reduced complications compared to ECMO in patients with cardiogenic shock 3, 4, 5.
- Patient selection is crucial for invasive treatments of HOCM, including procedures such as alcohol septal ablation and surgical myectomy 6.
- The use of Impella devices in patients with HOCM and cardiogenic shock requires further study to determine its safety and efficacy 2, 3, 4, 5.
Implications for Practice
- Clinicians should consider the potential benefits and risks of Impella use in patients with cardiogenic shock, including those with HOCM 3, 4, 5.
- Patient selection and individualized treatment planning are essential for optimal outcomes in HOCM patients 6.
- Further research is needed to guide clinical decision-making regarding Impella placement in HOCM and MODS patients 2, 3, 4, 5.