Varun Aggarwal MBBS MD FAAP FSCAI
Cardiogenic shock is a major source of morbidity and mortality in pediatric patients with cardiomyopathy or after cardiac surgery. While extracorporeal membrane oxygenation (ECMO) has been the traditional choice for these patients who are critically sick and need a short term mechanical circulatory support, another emerging device (which was designed primarily for temporary cardiovascular support during percutaneous coronary artery interventions) is the Impella® heart pump (Abiomed, Danvers, MA).
Impella® first received Food and Drug Administration (FDA) clearance in 2008 and FDA PMA approval as safe and effective in 2015. The percutaneous options consist of the Impella 2.5 and Impella CP. These devices can be delivered percutaneously via a 12–14 French sheath. The Impella 5.0/LD and Impella 5.5 require surgical cutdown of the femoral or axillary artery prior to insertion of a 22 French sheath. Impella RP (right-sided Impella) is inserted percutaneously via femoral venous access (23 French introducer sheath) [https://www.heartrecovery.com/products-and-services/impella, accessed 6-30-2021]. This allows meeting the varying needs of patients of different sizes and varying hemodynamic needs.
Impella® is a continuous flow miniature axial flow pump contained within a single pigtail catheter that can be inserted percutaneously or via a surgical cut-down. Blood is expelled from the ventricle to the outflow tract by rotating an Archimedes screw inside a thin, hollow pipe that traverses the aortic or the pulmonary valve (left-sided or right-sided Impella device respectively). The efficient extraction of blood from the left ventricle improves mean arterial pressure, peripheral tissue perfusion and slightly reduces pulmonary capillary wedge pressure. This, therefore, helps unload the ventricle and therefore facilitates cardiac recovery. In fact, the addition of Impella on top of venoarterial-ECMO support (referred to as ECPella) has gained interest as it might portend improved outcomes in patients with cardiogenic shock.
Pediatric use of the device has been increasingly adopted [5-9] in many centers across the United States but still remains limited. Some of the limitations of the use of the device in pediatric patients include constraints of the vessel (femoral or others) size, heart size (to accommodate the Impella device), or the pure availability of expertise to implant and monitor post device placement. The development of new circulatory support technologies for the pediatric population is a major challenge due to the size and vulnerability of this population as well as the heterogeneity of the disease. Morray et al  have provided anthropomorphic and anatomic measurements to guide providers in pediatric patient selection for MCS using the Impella devices. Further miniaturization of the device in the future will allow this technology to be more widely applicable to small pediatric patients. In the meantime, the Impella can be very useful in appropriately selected pediatric patients for temporary support and result in improved outcomes.
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- Kawashima D, Gojo S, Nishimura T, Itoda Y, Kitahori K, Motomura N, et al. Left ventricular mechanical support with Impella provides more ventricular unloading in heart failure than extracorporeal membrane oxygenation. ASAIO J. 2011;57(3):169-76.
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