Alak, Çetin

The Impella 5.5 is an axillary mechanical circulatory support device used in patients with cardiogenic shock, but those with small left ventricular (LV) cavities may be at risk for suction events, hemolysis, malpositioning, hypoperfusion, and LV injury. Informally accepted guidelines, extrapolated from durable LVAD studies, suggest a minimum left ventricular internal dimension in diastole (LVIDd) of 58 mm, with some clinical practices using a more stringent ≤52 mm cutoff. We retrospectively analyzed 154 consecutive patients supported with Impella 5.5 between January 2020 and December 2024. Overall, 38 patients had an LVIDd ≤58 mm, and 116 had an LVIDd >58 mm; a key subgroup of 21 patients presented with a very small LVIDd of ≤52 mm]. Baseline demographics, comorbidities, body mass index, and renal function were similar [across groups], although those with larger LVIDd had lower ejection fractions (16% vs. 24%, p = 0.001). Median support duration was 24 days in all groups, and pre- and post-implant hemodynamic and laboratory improvements were comparable. Rates of transplantation (79% vs. 90%, p = 0.088) and LVAD implantation (2% vs. 6%, p = 0.159) did not differ significantly in the ≤58 mm cohort. Notably, within the ≤52 mm subgroup, 90-day survival remained high at 90.5% ( p = 0.336), with significant improvements in right atrial pressure (17 to 10 mmHg, p = 0.041), mean pulmonary artery pressure (36 to 26 mmHg, p = 0.008), and eGFR (45 to 57 mL/min/1.73m 2 , p = 0.003). Remarkably, native cardiac recovery was observed exclusively in the smaller LV cohorts, occurring in 11% of the ≤58 mm group ( p = 0.003 vs. 0%, p = 0.003) and reaching 19% in the ≤52 mm group (vs. 0% in larger cavities, p < 0.001), while durable LVAD escalation was entirely avoided in the ≤52 mm cohort (0% vs. 6%). Ninety-day event-free survival was excellent across all cohorts 92% vs. 96% in the primary analysis, with no major device-related complications, suction events, clinically significant hemolysis, bleeding, stroke, or escalation to Bi-VAD support. These findings strongly support the safety and feasibility of Impella 5.5 in extremely constrained, small LV cavities.

Background: Renal dysfunction is a known prognostic factor in advanced heart failure and among patients receiving temporary mechanical circulatory support (tMCS). However, the predictive value of post-Impella creatinine in determining healthcare resource utilization in patients bridged to transplant with Impella 5.5 remains unclear. This study aimed to evaluate the association between post-Impella creatinine and key hospitalization metrics in this population. Methods: We performed a retrospective cohort study of patients who received Impella 5.5 as a bridge-to-transplant between January 2020 and January 2025. Serum creatinine was collected 72 hours after Impella placement. The primary outcome was device-to-discharge time. Secondary outcomes included transplant-to-discharge time, post-transplant ICU length of stay (LOS), and total LOS (admission-discharge). Univariate and multivariable linear regressions were used to examine the association between post-Impella creatinine and each outcome, adjusting for age, gender, BMI, and LVEF. Results: 133 patients were supported with the Impella 5.5 as BTT and were included (median age 58 years (51–65), 82.7% were male, and 71.4% presented with non-ischemic cardiomyopathy. The median BMI was 27.7 (24.3–32.3), LVEF 17% (15–22), and post-Impella creatinine 1.32 mg/dL (0.96–1.71). The median device-to-discharge time was 45 days (29-64), transplant-to-discharge time was 14 days (12–19), ICU LOS post-transplant was 6 days (4–8), and total LOS was 58 days (42–76). Higher post-Impella creatinine was significantly associated with longer device-to-discharge time (β = 6.67, p = 0.004), longer transplant-to-discharge duration (β = 3.42 p = 0.003), longer ICU LOS (β = 2.19, p = 0.007), and longer total LOS (β = 7.24, p = 0.002) on univariate analysis. Post-impella creatinine remained significantly associated with device-to-discharge time in the multivariate model after adjusting for confounders (β = 6.33, p = 0.006). Importantly, this suggests that patients with lower post-Impella creatinine levels may experience shorter hospitalizations and faster recovery trajectories following transplant. Conclusions: Post-Impella creatinine is a significant predictor of prolonged hospitalization in patients supported with Impella 5.5 as a bridge to transplant. These findings emphasize the prognostic importance of early renal function assessment and may guide risk stratification and resource planning in advanced heart failure care.

Background: Right atrial thrombus (RAT), though rare, carries a high risk of pulmonary or systemic embolism and a 25–44% mortality rate. In LVAD candidates, coexisting RAT significantly complicates perioperative management due to their critical condition and high risk of decompensation during surgery. Percutaneous thrombectomy offers a less invasive, lower-risk alternative to open surgery, enabling faster recovery. Case Presentation: We present a case of a 76-year-old male with ischemic cardiomyopathy and heart failure secondary to Adriamycin chemotherapy with an ejection fraction (EF) of 26%, diabetes mellitus, and stage 3 chronic kidney disease, scheduled for left ventricular assist device (LVAD) implantation. Preoperative echocardiography revealed a large, multilobulated, mobile thrombus in the right atrium. Given the high surgical risk and thrombus mobility, percutaneous thrombectomy using the AngioVac system (Angiodynamics, Latham, NY, USA) was performed. The thrombus was successfully removed, and the patient was discharged on apixaban for long-term anticoagulation. Advanced medical therapy and transplant/durable LVAD evaluation were delayed by 35 days to allow for the stabilization of any postoperative effects. Conclusions: This case underscores the efficacy of percutaneous thrombectomy as a bridge to LVAD in high-risk patients, reducing thromboembolic complications and supporting safe LVAD implantation.

Background: The Society for Cardiovascular Angiography and Interventions (SCAI) staging system is a crucial tool for categorizing cardiogenic shock (CS) and guiding interventions. SCAI staging is traditionally static and may not capture dynamic changes. We evaluated the impact of axillary mechanical circulatory support and SCAI stage transition in patients with CS supported until heart transplantation. Methods: A retrospective study was conducted on patients with Impella support as bridge to transplant. Hemodynamic and vasoactive support parameters were collected and SCAI stage recorded at baseline and after 72 hours. Results: 36 patients were included in the analysis. The median age was 61 (52 – 68) with an EF of 19% (15-26%) (Figure 1). Before Impella placement, the distribution of patients across SCAI stages was as follows: 19 patients in SCAI B, 8 patients in SCAI C, and 9 patients in SCAI D. After 72 hours of Impella support, 7 patients initially classified as SCAI C transitioned to SCAI B with one deteriorating to SCAI D (Figure 2). Patients in SCAI D showed notable improvement, with 8 out of 9 patients transitioning to SCAI B. For patients initially SCAI B, RA changed from 10 to 11 mmHg, and PCWP decreased from 23 to 17 mmHg. The Fick CI increased from 2.53 to 3.02 L/min/m 2 (p=0.04), and the vasoactive inotropic score (VIS) decreased from 7.5-5.0 (p=0.05). In patients initially classified as SCAI C, RA pressure decreased from 13 to 8 mmHg, and PCWP reduced from 32 to 30 mmHg. The Fick CI improved from 1.79 to 2.61 L/min/m 2 (p<0.001), while the VIS decreased from 9.2 to 6.3 (p=0.004). For those initially in SCAI D, RA pressure reduced from 8 to 5 mmHg, and PCWP decreased from 27 to 18 mmHg. The Fick CI increased from 1.55 to 2.67 L/min/m 2 (p=0.002), and the VIS was notably reduced from 4.75 to 3.8 (p=0.36). All 36 patients survived to heart transplantation without major pre-transplant complications. Conclusion: SCAI stage C-E mortality ranges from 25 – 50% or worse. Implementing Impella 5.5 support reduced SCAI severity and may be associated with improved survival in HFCS. We demonstrated lower VIS after Impella 5.5 and a 100% event free survival to heart transplantation despite a 25% baseline SCAI D cohort. Larger data should be evaluated to assess this trend.