Differential Utilization of Impella Devices, ECMO, and Combined Therapies as Escalation and De-escalation Strategies

This paper discusses escalation, de-escalation, weaning, and bridging from percutaneous ventricular assist devices (pVADs) in patients with cardiogenic shock. These decisions, the authors write, depend on “the underlying disease, comorbidities, native heart function, right heart function, and the circulatory demand of the patient.”

The authors explain that the insertion of a pVAD in patients with cardiogenic shock can augment cardiac output and improve end-organ perfusion. Devices include intra-aortic balloon pumps (IABPs), microaxial flow pumps (mAFPs) such as Impella®, extracorporeal membrane oxygenation (ECMO), and a combination of Impella and ECMO known as ECMELLA. They emphasize the importance of identifying patients who do not respond to initial treatment and escalating support early to optimize the chances of reversing multiorgan failure and the rapid downward spiral in fulminant CS. “A direct approach targeting the cause of CS with the appropriate device increases the chances of success of the therapy while minimizing the occurrence of major complications.”

De-escalation, the authors state, “does not necessarily mean less systemic support by pump flow, but rather the shift to a less invasive pump, in univentricular configuration and upper body (axillary) cannulation to promote patient mobilization and ambulation.” They discuss why de-escalation is useful and when to consider de-escalating patients. They explain that de-escalating patients to support with an axillary Impella allows for mobility as well as extubation and oral feeding while continuing to receive hemodynamic support. This strategy, the authors write, allows for an “extended period for native heart recovery, especially if it provides full unloading and implementation of heart failure medications, and for resolution of intercurrent clinical conditions, such as infections and end-organ damage.”