title: Using the Minimally Invasive Impella 5.0 via the Right Subclavian Artery Cutdown for Acute on Chronic Decompensated Heart Failure as a Bridge to Decision.
abstract: BACKGROUND
  Outcomes of traditional mechanical support paradigms (extracorporeal membrane oxygenation, intraaortic balloon pump [IABP], and permanent left ventricular assist device [LVAD]) in acute decompensated heart failure have generally been suboptimal. Novel approaches, such as minimally invasive LVAD therapy (Impella 5.0 device), promise less invasive but equivalent hemodynamic support. However, it is yet unknown whether the outcomes with such devices support widespread acceptance of this new technology. We recently started utilizing the right subclavian artery (RSA) for Impella 5.0 implantation and report our early experience and outcomes with this novel approach.
  
  
  METHODS
  A single-center retrospective review was performed of 24 patients with acute on chronic decompensated heart failure who received the Impella 5.0 via the RSA from June 2011 to May 2014. The device was implanted via a cutdown through an 8-mm vascular graft sewn to the RSA. The device was positioned with fluoroscopy and transesophageal echocardiography.
  
  
  RESULTS
  The mean age of the patients was 51.29 years, and 75% were male. At implantation, all patients were mechanically ventilated on at least 2 inotropes with persistent cardiogenic shock, and 17 (70.8%) were on IABP support. Postimplantation, 21 (87.5%) tolerated extubation, and all 17 of the patients with IABPs tolerated discontinuation of IABP support. The reduction in the Model for End-Stage Liver Disease score preimplantation vs postimplantation was statistically significant (21.17 vs 14.88, P=0.0014), suggesting improvement in end organ function. A significant decrease was also seen in creatinine levels before and after implantation (2.17 mg/dL vs 1.50 mg/dL, P=0.0043). The endpoint of support included recovery in 6 patients (25.0%), permanent LVAD in 9 (37.5%), and heart transplantation in 2 (8.3%). Death occurred in 7 patients (29.2%) as a result of multisystem organ failure, infection, or patient withdrawal of care.
  
  
  CONCLUSIONS
  Minimally invasive LVAD therapy using the Impella 5.0 via the RSA cutdown is an attractive option in acute on chronic decompensated heart failure. Improvement in end organ function allows for transition to recovery or to advanced surgical therapies such as permanent LVAD and heart transplantation. Significant advantages to this approach include improved left ventricular unloading, lower anticoagulation need, and the potential for ambulation and physical therapy.
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Aditya
authors.initials: A
authors.lastname: Bansal
authors.affiliation: Department of Cardiothoracic Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA.
authors.forename: Jay K
authors.initials: JK
authors.lastname: Bhama
authors.affiliation: The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA ; Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Rajan
authors.initials: R
authors.lastname: Patel
authors.affiliation: Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Sapna
authors.initials: S
authors.lastname: Desai
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Stacy A
authors.initials: SA
authors.lastname: Mandras
authors.affiliation: Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Hamang
authors.initials: H
authors.lastname: Patel
authors.affiliation: Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Tyrone
authors.initials: T
authors.lastname: Collins
authors.affiliation: Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: John P
authors.initials: JP
authors.lastname: Reilly
authors.affiliation: The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA ; Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Hector O
authors.initials: HO
authors.lastname: Ventura
authors.affiliation: Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: P Eugene
authors.initials: PE
authors.lastname: Parrino
keywords: Axillary artery; creatinine; heart-assist devices; minimally invasive surgical procedures; shock–cardiogenic