Effect of Impella 5.5 on Preexisting Functional Mitral Regurgitation in Patients with Heart Failure-Related Cardiogenic Shock

Rachna Kataria; Abdurrahman Khalil; Erin Coglianese; Jerome Crowley; Michael G Silverman; Kenneth Shelton; Eriberto Michel; David D'Alessandro; Van-Khue Ton

doi:10.1016/j.shj.2022.100072

Effect of Impella 5.5 on Preexisting Functional Mitral Regurgitation in Patients with Heart Failure-Related Cardiogenic Shock

Struct Heart. 2022 Aug 4;6(4):100072. doi: 10.1016/j.shj.2022.100072. eCollection 2022 Aug.

Authors

Rachna Kataria¹, Abdurrahman Khalil², Erin Coglianese¹, Jerome Crowley³, Michael G Silverman², Kenneth Shelton³, Eriberto Michel⁴, David D'Alessandro⁴, Van-Khue Ton¹

Affiliations

¹ Division of Advanced Heart Failure and Transplant Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
² Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³ Division of Critical Care and Pain Management, Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁴ Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

Background: Heart failure-related cardiogenic shock (HF-CS) is increasingly common. Moderate/severe functional mitral regurgitation (FMR) is commonly seen in patients presenting with decompensated heart failure and is associated with worse outcomes. Percutaneous mechanical circulatory support devices are increasingly used to provide hemodynamic support for ongoing CS. There is no description of the impact of Impella device on hemodynamic response when used in combination with preexisting FMR.

Methods: Retrospective review of patients aged ≥18 years, who underwent Impella 5.5 implant for HF-CS, and who had a transthoracic echocardiogram performed pre- and post-Impella.

Results: Of 24 patients, 33% had moderate-to-severe/severe FMR, 38% had mild-moderate/moderate FMR, and 29% had trace/mild FMR on pre-Impella transthoracic echocardiogram. Additional right ventricular assist device was simultaneously inserted in 3 patients, of whom 1 had severe, 1 had moderate, and another had mild FMR pre-Impella. Despite maximally tolerated Impella unloading, 6 patients (25%) had persistent moderate-severe/severe FMR, and 9 (37.5%) patients had persistent moderate FMR. Overall, however, there was a decrease in central venous pressure, pulmonary artery diastolic pressure, serum lactate, and vasoactive-inotrope score at 24 hours post-Impella, and survival was high at 83%.

Conclusions: In a retrospective cohort of patients admitted with HF-CS who underwent Impella 5.5 implant for hemodynamic support, Impella did not seem to acutely ameliorate FMR severity. Despite this, there was a significant improvement in hemodynamic response at 24 hours post-Impella. In carefully selected patients, especially those with isolated left ventricular failure, Impella 5.5 may provide adequate hemodynamic support even in the presence of higher severity FMR.

Keywords: Cardiogenic shock; Functional mitral regurgitation; Heart failure; Impella.