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06.08.2018 | Original Article Open Access

Mechanical Unloading by Fulminant Myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA Concepts

Zeitschrift:
Journal of Cardiovascular Translational Research
Autoren:
Carsten Tschöpe, Sophie Van Linthout, Oliver Klein, Thomas Mairinger, Florian Krackhardt, Evgenij V. Potapov, Gunther Schmidt, Daniel Burkhoff, Burkert Pieske, Frank Spillmann
Wichtige Hinweise
Associate Editor Enrique Lara-Pezzi oversaw the review of this article

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s12265-018-9820-2) contains supplementary material, which is available to authorized users.
Clinical relevance:
This review is of clinical relevance since it:
• gives an overview of different mechanic support systems by fulminant myocarditis;
• provides evidence that LV unloading by Impella exhibits disease-modifying effects important for myocardial recovery;
• addresses the question of how to define the appropriate time point for weaning strategies and for changing or discontinuing unloading in fulminant myocarditis.

Abstract

Mechanical circulatory support (MCS) is often required to stabilize patients with acute fulminant myocarditis with cardiogenic shock. This review gives an overview of the successful use of left-sided Impella in the setting of fulminant myocarditis and cardiogenic shock as the sole means of MCS as well as in combination with right ventricular (RV) support devices including extracorporeal life support (ECLS) (ECMELLA) or an Impella RP (BI-PELLA). It further provides evidence from endomyocardial biopsies that in addition to giving adequate support, LV unloading by Impella exhibits disease-modifying effects important for myocardial recovery (i.e., bridge-to-recovery) achieved by this newly termed “prolonged Impella” (PROPELLA) concept in which LV-IMPELLA 5.0, implanted via an axillary approach, provides support in awake, mobilized patients for several weeks. Finally, this review addresses the question of how to define the appropriate time point for weaning strategies and for changing or discontinuing unloading in fulminant myocarditis.

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Zusatzmaterial
Movie 1 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with fulminant myocarditis and a prolonged Impella 5.0 support (PROPELLA concept) at day 21. A (movie 1): Full Impella 5.0 support at level P8: 5.2 L/min and severe reduced LV function. (MP4 871 kb)
12265_2018_9820_MOESM1_ESM.mp4
Movie 2 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with fulminant myocarditis and a prolonged Impella 5.0 support (PROPELLA concept) at day 21. B (movie 2): Temporary reduction of Impella 5.0 support at level P1: 1.2 L/min, showing an immediate increase in LV function indicating that reduced LV function during full circulatory support (movie 1) belongs to a beneficial LV unloading mechanism and can be used as a sign for recovery. A temporary pump flow reduction maneuver under echocardiographic evaluation is useful in clinical practice for assessing suitability for weaning of the PROPELLA-concept. (MP4 786 kb)
12265_2018_9820_MOESM2_ESM.mp4
Movie 3 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with cardiogenic shock based on a fulminant myocarditis and maximal mechanical circulatory support with ECLS and Impella (ECMELLA concept) at day 7. A (movie 3): Reduced ECMELLA support (ECLS flow 2.4 L/min, Impella CP at level P6: 2.4 L/min showing reduced LV function. (MP4 873 kb)
12265_2018_9820_MOESM3_ESM.mp4
Movie 4 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with cardiogenic shock based on a fulminant myocarditis and maximal mechanical circulatory support with ECLS and Impella (ECMELLA concept) at day 7. B (movie 4): Temporary reduction of ECLS flow 1.8 L/min and Impella CP at level P1: 0.8 L/min, showing an immediate increase in LV function indicating that reduced LV function during higher circulatory support (movie 3) belongs to a beneficial unloading mechanism and can be used as a sign for recovery. A temporary pump flow reduction maneuver under echocardiographic evaluation is useful in clinical practice for assessing suitability for weaning of the ECMELLA-concept. (MP4 889 kb)
12265_2018_9820_MOESM4_ESM.mp4
Movie 5 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with ischemic cardiomyopathy at day 7. A (movie 5): Full Impella CP support at level P8: 3.4 L/min and severe reduced LV function. (MP4 1195 kb)
12265_2018_9820_MOESM5_ESM.mp4
Movie 6 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with ischemic cardiomyopathy at day 7. B (movie 6): Temporary reduction of Impella CP support at level P1: 1.2 L/min, showingno change in LV function, indicating that no LV function recovery can be expected at this time point. (MP4 1119 kb)
12265_2018_9820_MOESM6_ESM.mp4
Movie 7 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with cardiogenic shock based on an acute myocardial infarction under maximal mechanical circulatory support with ECLS and Impella (ECMELLA concept) at day 8. A (movie 7): Reduced ECMELLA support (ECLS flow 2.0 L/min, Impella CP at level P6: 2.4 L/min showing severe reduced LV function. (MP4 776 kb)
12265_2018_9820_MOESM7_ESM.mp4
Movie 8 Temporary pump flow reduction maneuver under echocardiographic evaluation in a patient with cardiogenic shock based on an acute myocardial infarction under maximal mechanical circulatory support with ECLS and Impella (ECMELLA concept) at day 8. B (movie 8): Temporary reduction of Impella CP at level P1: 0.8 L/min under reduced ECLS flow of 1.0 L/min, showing a close to comparable LV function, indicating that no LV function recovery can be expected at this time point. (MP4 347 kb)
12265_2018_9820_MOESM8_ESM.mp4
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