Is the 'Unprotected Heart' a clinical myth? Use of IABP, Impella, and ECMO in the acute cardiac patient

摘要

Altering hemodynamics through intravascular mechanical devices has been a major practice change over the past 20 years. The physiologic advantages of these devices are enticing. With intra-aortic balloon pumps (IABP), we can improve coronary perfusion pressures. With Impella (Abiomed, Boston, MA), we can reduce left ventricular distension and lower end-diastolic pressure. With extracorporeal membrane oxygenation (ECMO), we can improve perfusion, oxygenation, and ventilation. Each of these devices comes at a physiologic cost. These costs can potentially outweigh the benefits they provide. The question in 2019 is who should be receiving these devices? In this edition of Resuscitation, Davidsen etal. share their nearly 10-year experience on Impella use in cardiac arrest and cardiogenic shock.1 The authors should be commended on their accumulation and synthesis of 92 patients. This data adds to the growing research on outcomes with use of Impella. They found that patients with ongoing CPR did worse than those who obtained return of spontaneous circulation (ROSC). Likewise, ROSC patients did worse than those who did not arrest. Subgroup analysis found hypertension and older age to be predictive of death.