Impella

 Impella RP is contraindicated in patients with pulmonic insufficiency because the increased

blood flow in the pulmonary artery will make it worse. It is also a relative contraindication in
patients following tricuspid valve replacement and repair due to the position of the device
across the operative site (christoper)
 The Impella (Abiomed) is a transvalvular continuous micro-axial flow device designed to
propel blood from the left ventricle (LV) into the aorta via an Archimedes screw pump. In the
setting of CS, the Impella device unloads the ventricle, reduces ventricular end-diastolic
pressure, increases mean arterial pressure, and decreases myocardial oxygen consumption
(kartik)
 The Impella 2.5 can provide approximately 2.5 L/min of flow, and the Impella CP is an
intermediate device that can provide up to 4.0 L/min. Both of these LV support systems are
commonly placed percutaneously in the femoral artery using an introducer sheath and
advanced in a retrograde fashion across the aortic valve under fluoroscopic guidance. In
contrast, the LV Impella 5.0 (21F motor) requires a surgical cut down, insertion of a vascular
graft to the axillary artery, and use of a 23F introducer sheath. Most recently, Abiomed’s
newest heart pump, the Impella 5.5 with SmartAssist, has received premarket approval from
the US Food and Drug Administration (FDA) for safety and efficacy in the therapy of
cardiogenic shock up to 14 days. The Impella 5.5 with SmartAssist delivers thrombus,
mechanical aortic valve, and severe PAD (when using a femoral access approach).
Contraindications for the RP Impella include right-sided mechanical valves, severe tricuspid
or pulmonary stenosis, thrombus, and the presence of an inferior vena cava filter. General
complications related to the Impella systems include device migration too far into the LV or
underneath the mitral valve apparatus, placing the patient at risk for
perforation/tamponade, ventricular arrhythmias, acute mitral regurgitation, hemolysis, and
thrombotic complications (kartik)
 The Impella requires systemic anticoagulation. Complications include bleeding, vascular
injury, infection, and hemolysis. Another concern is pump migration if the catheter becomes
dislodged in any way. Contraindications include LV thrombus, moderate aortic stenosis or
aortic insufficiency, recent stroke or TIA, and structural abnormalities of the Aorta (nisha)

IABP

 The IABP consists of a balloon catheter and a pump console to control the timing of balloon
inflation and deflation. The catheter is a double-lumen, 7.5- to 8.0-French (F) catheter with a
polyethylene balloon attached at its distal end, with one lumen of the catheter attached to
the pump and used to inflate the balloon with gas. Helium is used because its low viscosity
facilitates rapid transfer in and out of the balloon, and because it absorbs very rapidly in
blood if the balloon ruptures. Timing of balloon inflation and deflation is based on
electrocardiogram (ECG) or pressure triggers. (Braunwald)
 The 2012 IABP-SHOCK II (Intraaortic Balloon Support for Myocardial Infarction with
Cardiogenic Shock) trial demonstrated that IABP use compared to medical therapy
immediately before revascularization did not reduce 30- day mortality in patients with AMI
complicated by CS (kartik)
 The IABP is placed via arterial access, most commonly femoral, into the descending aorta
(Ao). During diastole, the balloon inflates, providing an augmented diastolic pressure and
coronary perfusion. During systole, the balloon deflates rapidly, creating a temporary
vacuum that reduces aortic pressure (ie, afterload) and enhances left ventricular (LV)
 unloading. Overall effects of the IABP are a modest increase in cardiac output and stroke
volume; decrease in LV preload, LV end diastolic pressure, LV wall stress, and afterload; and
improved coronary perfusion and systemic blood pressure (Nisha).

ECMO

 The absolute contraindication to VA ECMO is no expectations of recovery without a pathway

to durable support. If that cannot be determined, VA ECMO may be considered as a “bridge
to candidacy.” Ideally, a reasonable timeline for recovery should be set before implantation
to guide withdrawal of support when neither recovery nor alternative treatments exist.
Other relative contraindications include (1) age, (2) obesity, (3) preexisting conditions that
affect quality of life (neurologic status or advanced malignancy), and (4) risk of
uncontrollable haemorrhage. VV ECMO is contraindicated for acute respiratory failure if
there is minimal chance of lung recovery (christoper).

Tandem heart

 The TandemHeart system (Cardiac Assist, Inc.) is a percutaneous centrifugal ventricular

assist device that unloads the failing LV by pumping oxygenated blood directly from the left
atrium into the distal descending aorta. There are four major components of this device: the
control console, a 21F transseptal inflow cannula positioned in the left atrium, an arterial
outflow cannula (15-19F), and the centrifugal pump. The pump has a brushless
electromagnetic motor and provides up to 5.0 L/min of flow at a maximum speed of 7500
rpm.6,25 The venous and arterial cannulas are secured in the groin to prevent cannula
migration. This device requires highly trained operators who are skilled in transseptal and
large-bore access to insert the system under fluoroscopic guidance. Due to the parallel
configuration relative to the native heart, both the TandemHeart device and the native LV
may contribute to forward flow, creating the net effect of reductions in LV pressure, volume,
and stroke volume. (kartik)
 TandemHeart arm had improved hemodynamics (ie, higher cardiac power index and lower
pulmonary capillary wedge pressure) but more complications (ie, severe bleeding and limb
ischemia) compared to the IABP arm.26,27 (kartik)
 TandemHeart is not FDA approved for RV support (RA to pulmonary artery), but cases
showing feasibility have been reported. Indications for RV MCS include cardiogenic shock
related to RV myocardial infarction, acute pulmonary embolus, severe pulmonary
hypertension, and post-LVAD RV failure.28,2 (kartik)
 TandemHeart. The TandemHeart System® (CardiacAssist, Inc.) is a LA to femoral artery
bypass system (Fig. 1). This pVAD consists of a 21F venous transseptal inflow cannula, a
continuous flow centrifugal blood pump with an electromagnetically suspended and driven
impeller, and an arterial perfusion catheter. Oxygenated blood is withdrawn from the LA;
which is accessed by standard transseptal technique involving placement of the 21F cannula,
which contains 14 side holes and a large end hole; and pumped to the systemic circulation
via a 17F femoral artery catheter, thereby bypassing the left heart. Patients should undergo
an aortogram with runoff to assess the degree of peripheral vascular disease prior to
catheter insertion. RV support can be achieved by placing the inflow cannula in the RA and
outflow cannula in the PA. The TandemHeart pump can also be surgically implanted similar
to the CentriMag described above to support either or both ventricle (Nisha)
 Contraindications include ventricular septal defect (which would then cause right to left
shunting and hypoxemia), aortic insufficiency, severe peripheral vascular disease, and
inability to be on systemic anticoagulation. The TandemHeart has several possible
complications, and percutaneous placement requires an experienced operator familiar with
the technique of transseptal puncture. Complications include distal limb ischcemia, bleeding,
infection, tamponade because of perforation at the time of transseptal puncture,
thromboembolism, and air embolism at the time of insertion of large cannulae (Nisha)
 A final indication includes mechanical complications of AMI (i.e., ventricular septal rupture,
mitral regurgitation, or free wall rupture) as a bridge to surgical repair which is still a class
IIa/C recommendation for IABP placement in European guidelines
 It is hypothesized that the Impella device, by direct unloading, may reduce infarct size,
particularly when starting pre-PCI in patients with AMICS who are revascularized [39].
Patients with CS who were treated with pVAD (Tandem Heart® or Impella®) had a
significantly higher mean arterial pressure and a faster decrease in lactate levels compared
with patients treated with IABP
 In the past decade, a larger-capacity (50-cc) IABP was introduced into clinical practice.
Compared with previously used 40-cc IABPs, patients who received a 50-cc IABP showed
higher-peak augmented diastolic pressure, higher magnitude of diastolic augmentation, and
a greater slope and magnitude of deflation pressure from peak augmented diastolic pressure
to reduced aortic end-diastolic pressure [44]. In 50-cc IABP recipients, diastolic pressure and
PA occlusion pressure were reduced, and CO, cardiac index, and PA oxygen saturation were
increased, while these PA catheter–derived measurements did not significantly change in
patients with a 40-cc IABP.
 Although other MSCDs like Impella, Tandem Heart, or VAECMO provide more hemodynamic
support, (first-line) IABP has multiple advantages. First of all, it is relatively cheap [1] and
IABPs are largely available and applicable, also in nontertiary centers. Insertion of an IABP
device is more straightforward and can be performed in the intensive care unit without the
need for fluoroscopy. Compared with other devices, IABP placement is associated with
fewer adverse events like vascular complications or hemolysis. Although mobilization of
patients with femoral IABPs is compromised, placement in the axillary or subclavian artery
allows mobilization and early physical rehabilitation. When the IABP fails or cannot be
weaned, rapid escalation is possible to percutaneous MCSDs, VA-ECMO, or advanced HF
therapies like durable MCSDs (e.g. LVAD) or orthotopic heart transplant (OHT). Finally, an
IABP is easily removed and the presence of an IABP does not complicate native heart
excision in case of bridging to OHT.
 The hemodynamic effects of an IABP stand out better with larger balloon size. Several recent
studies demonstrate that the use of larger 50-cc balloons resulted in a greater reduction in
cardiac filling pressures and increased CO compared with the 40-cc IABPs [44–46].
Unfortunately, 50-cc IABPs were generally not used in the major landmark studies so far,
since the 50-cc IABP was only introduced in 2012. Since the number of patients achieving
optimal hemodynamic benefit from IABP activation may be < 50% with the older 30–40-cc
IABPs, this could potentially have contributed to the failure of previous IABP studies [44]
 Several limitations of the IABP-SHOCK II should be mentioned. As discussed previously, most
patients were treated with conventional, small-volume IABP-catheters. Besides, 10% of
patients in the control group experienced crossover to IABP. Moreover, since almost half of
all patients were included after cardiopulmonary resuscitation, a substantial amount might
have died due to post-anoxic damage. Finally, a large percentage of patients in this trial were
already on vasopressors/inotropes (90%), and thus IABP therapy might have been initiated
too late
 The proportion of patients successfully weaned from IABP in CS is significantly lower in
patients with STEMI compared with patients with NSTEMI and congestive HF
 Intra-aortic balloon pumping (IABP) is a fascinating example of left ventricular assistance
from a biophysical, a physiological and a practical point of view. The key objective of IABP is
an improvement in the energy balance of the heart, which is achieved by increasing the
oxygen supply to the ischemic myocardium and concomitantly diminishing the heart's
oxygen consumption. Recently, however, the appropriateness of intra-aortic balloon pump
(IABP) counterpulsation in patients with cardiogenic shock (CS) has been the subject of
significant debate.3,4 Indeed, an adequately powered, randomized trial of IABP in patients
with CS secondary to myocardial infarction (IABP-SHOCK II) has demonstrated neither a
survival benefit for IABP support in comparison with the control, nor any benefit with
respect to secondary outcomes.3,4 For this reason, IABP has been downgraded in current
American and European guidelines (Karim)
 We suggest that IABP can be considered in patients with CS with acute mitral regurgitation
or a ventricular septal defect, and it can be considered in select patients with profound CS
when other MCS devices are not available, are contraindicated, or cannot be placed.