Bridging with surgical implanted Impella devices

This study by Gill et al. [1] presents the results of the Impella 5.0 and 5.5 devices in a high-volume centre. This study underlines several, in part already known, aspects. Overall outcomes are good for patients requiring short-term devices. There are some interesting findings: first, in an experienced centre following dedicated protocols, excellent outcomes can be achieved [2]. Second, heart teams and, specifically in this context ‘shock teams’, are important. This study from a large advance heart failure centre in the USA has the capacity to provide all forms of care to patients with advance heart failure and cardiogenic shock. These teams must define the best treatment strategies for each individual patient. But there are differences in Europe with regard to the alternatives: in 2018, the heart allocation policy for heart transplantation changed in the USA: patients with short-term devices are prioritized in comparison to the former policy. In addition, organ donation rates are higher and donor age is younger in the USA compared to Europe, which leads to shorter waiting times. The axillary-implanted Impella device allows ambulation of patients and has a 30-day approval [3]. Based on the expected support time, it is likely that a patient on the waiting list receives an Impella 5.0 or 5.5 allowing ambulation and gets transplanted in a reasonable time without receiving a durable VAD as bridge. Therefore, it is all about the alternatives [4]. While in countries with short waiting times and prioritization of patients waiting on a short-term device the post-heart transplant outcomes are acceptable, those who do not receive a donor heart and those who cannot be transplanted and need a durable device (LVAD) have worse outcomes compared to countries with longer waiting times. In early series of Impella-bridged patients to durable devices, 1-year outcomes can be close to 90% [3, 5]. In an upcoming multicentre retrospective study, the same findings will be presented. This is in part explained by optimization pre-LVAD and selecting patients with acceptable right ventricular function. But, in the present study, in some patients, the Impella pump was used in addition to an extracorporeal life support device (ECLS) or temporary right ventricular assist device. While unloading of the left ventricle by an Impella seems to be beneficial in comparison to ECLS alone [6], it is known that ECLS-bridged LVAD recipients have an 1-year survival of around 50% [7].

When looking for the best bridging concept even as positive thinking heart failure and shock teams, we should also look after those who fell off the bridge to the next therapy or died after bridging. In the present study, almost 20% died when bridged by an Impella only and 60% in patients with biventricular support while on short-term device support. The exact reasons are unclear. This can be attributed to the patient condition before Impella implantation or because of complications while on the devices. In the future, we should also look at these patients and identify those who need a different way of bridging and how to avoid complications. Guidance is needed not only who should receive such a device but also how these devices and patients should be managed [8, 9]. This allows stratification for the best individual treatment strategy.

Conflict of interest: Alexander M. Bernhardt has received honoraria, travel grants, consultancy fees and/or research support from Abbott, Abiomed, AstraZeneca, Berlin Heart, Medtronic and Novartis. Hermann Reichenspurner has received honoraria, travel grants, consultancy fees and/or research support from Abbott, Abiomed and Medtronic.

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