Early Career Editorial: Role of Impella® in Pediatric Mechanical Circulatory Support

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.[1] 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.[4]

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 [10] 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.

References

1. Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, et al. 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d’intervention. J Am Coll Cardiol. 2015;65(19):e7-e26.
2. 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.
3. Lemor A, Hosseini Dehkordi SH, Basir MB, Villablanca PA, Jain T, Koenig GC, et al. Impella Versus Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock. Cardiovasc Revasc Med. 2020;21(12):1465-71.
4. Meani P, Lorusso R, Pappalardo F. ECPella: Concept, Physiology and Clinical Applications. J Cardiothorac Vasc Anesth. 2021.
5. Parekh D, Jeewa A, Tume SC, Dreyer WJ, Pignatelli R, Horne D, et al. Percutaneous Mechanical Circulatory Support Using Impella Devices for Decompensated Cardiogenic Shock: A Pediatric Heart Center Experience. ASAIO J. 2018;64(1):98-104.
6. Qureshi AM, Turner ME, O’Neill W, Denfield SW, Aghili N, Badiye A, et al. Percutaneous Impella RP use for refractory right heart failure in adolescents and young adults-A multicenter U.S. experience. Catheter Cardiovasc Interv. 2020;96(2):376-81.
7. Lasa JJ, Castellanos DA, Denfield SW, Dreyer WJ, Tume SC, Justino H, et al. First Report of Biventricular Percutaneous Impella Ventricular Assist Device Use in Pediatric Patients. ASAIO J. 2017.
8. Yarlagadda VV, Maeda K, Zhang Y, Chen S, Dykes JC, Gowen MA, et al. Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation. J Am Coll Cardiol. 2017;70(18):2250-60.
9. Dimas VV, Morray BH, Kim DW, Almond CS, Shahanavaz S, Tume SC, et al. A multicenter study of the impella device for mechanical support of the systemic circulation in pediatric and adolescent patients. Catheter Cardiovasc Interv. 2017;90(1):124-9.
10. Morray BH, Dimas VV, McElhinney DB, Puri K, Qureshi AM. Patient size parameters to guide use of the Impella device in pediatric patients. Catheter Cardiovasc Interv. 2019;94(4):618-24.