Outcomes of impella use as prophylactic versus bailout strategy in patients undergoing non-emergent percutaneous coronary intervention
O'Neill WW, Moses JW, and Popma JJ. Outcomes of impella use as prophylactic versus bailout strategy in patients undergoing non-emergent percutaneous coronary intervention. Catheterization and Cardiovascular Interventions 2020; 95:S54-S55.
Catheterization and cardiovascular interventions
Background: Prophylactic support with Impella in hemodynamically stable patients undergoing non-emergent percutaneous coronary intervention (PCI), also termed Impella protected PCI, is now a well-established indication in a selective patient population at high risk for hemodynamic collapse during PCI. However some physicians may eschew preventive hemodynamic support and prefer a bailout strategy should hemodynamic collapse occur.
Methods: We aimed to compare the outcomes of patients entered in the cVAD prospective study who underwent Impella protected PCI (ProPCI group) with those who received bailout Impella support for cardiogenic shock onset during non-emergent PCI (Bailout group). A total of 1,028 patients supported with Impella 2.5 (34.9%) or Impella CP (65.0%) meeting the study inclusion criteria were entered into the cVAD database as of July 2019 (971 in ProPCI group and 40 in Bailout group). An additional 17 were identified in the USpella registry for a total of 57 Bailout patients. In this group the procedural complication leading to hemodynamic collapse was refractory hypotension in 37 (64.9%) patients and coronary perforation/dissection in 20 (35.1%).
Results: Females were more prevalent in the Bailout group (50.9% vs. 27.2%, p= 0.0002) and the median baseline LVEF was significantly higher (40% vs 30%, p<0.0001). In this group heart failure was less prevalent (42.1% vs 56.9%, p=0.04) as was left main disease (40.0% vs 56.1%, p=0.025). In-hospital mortality was significantly higher in the Bailout group (41.9% vs. 4.3%, p<0.0001) and was similar across patients experiencing hemodynamic collapse secondary to refractory hypotension or coronary perforation/dissection (48.7% vs. 50.0%, p=0.99). Though females were disproportionately more likely to require bailout support, female in-hospital mortality was excessively high but not significantly higher compared to male (55.2% vs 42.9%, p=0.43).
Conclusions: Failure to prospectively identify and prophylactically implement hemodynamic support in patients at high risk for hemodynamic collapse during non-emergent PCI leads to excessive in-hospital mortality. This failure to identify patients who would benefit from prophylactic support appears to be more prevalent in women.