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Review
. 2019 Apr;12(2):116-123.
doi: 10.1007/s12265-018-9820-2. Epub 2018 Aug 6.

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

Carsten Tschöpe  1   2   3 , Sophie Van Linthout  4   5   6 , Oliver Klein  5   6 , Thomas Mairinger  7 , Florian Krackhardt  4 , Evgenij V Potapov  6   8 , Gunther Schmidt  4 , Daniel Burkhoff  9 , Burkert Pieske  4   6   10 , Frank Spillmann  4   6
Affiliations
Review

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

Carsten Tschöpe et al. J Cardiovasc Transl Res. 2019 Apr.

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.

Keywords: Endomyocardial biopsies; Fulminant myocarditis; MALDI-imaging mass spectrometry; Mechanical circulatory support; Mechanical unloading; Metabolism; Weaning.

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Conflict of interest statement

Conflict of interest

CT receives lecturing fees from Abiomed and DB an unrestricted institutional educational grant from Abiomed.

Human subjects/informed consent statement

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from the patient for being included in the study.

Animal Studies

No animal studies were carried out by the authors for this article.

Figures

Fig. 1
Fig. 1
Impella-induced left ventricle venting under ECLS treatment: Concept of ECMELLA—left ventricle unloading. Left panel: invasive LV hemodynamic measurements under veno-arterial (v.a.) extracorporeal life support (ECLS) support indicate highly increased LV end-diastolic pressure (LVEDP) of 51 mmHg. Right panel: invasive LV hemodynamic measurements under ECMELLA concept illustrates immediate lowering of LVEDP to 43 mmHg already 50 s after onset
Fig. 2
Fig. 2
Chest X-ray of a BI-PELLA approach of a patient from our clinic with endomyocardial biopsy-proven severe fulminant myocarditis and biventricular decompensation. RV-Impella RP implanted into the right A. pulmonalis; LV-Impella CP implanted into the left ventricle
Fig. 3
Fig. 3
Impact of prolonged mechanical unloading on cardiac immune cell infiltration in chronic inflammatory cardiomyopathy (PROPELLA concept). Upper (× 100 magnification) and lower (× 200 magnification) panels depict hematoxylin and eosin-stained sections of endomyocardial biopsies isolated before (T0), during combined unloading and immune suppression (T1, T2) and after Impella explantation (T3). Unloading combined with immune suppression (T1, T2) decreases the extensive immune cell infiltration found at T0. However, after explantation of the Impella, immune cell infiltration is again prominent (T3)
Fig. 4
Fig. 4
Impact of prolonged mechanical unloading on cardiac metabolism in chronic inflammatory cardiomyopathy (PROPELLA concept). The intensity distribution of malate dehydrogenase, mitochondrial (1164 Da) is significantly increased during combined unloading and immune suppression (T1, T2) compared to before (T0) and after unloading (T3) implantation. Lower panel illustrates the corresponding box plot
See this image and copyright information in PMC

References

    1. Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, Fu M, Helio T, Heymans S, Jahns R, Klingel K, Linhart A, Maisch B, McKenna W, Mogensen J, Pinto YM, Ristic A, Schultheiss HP, Seggewiss H, Tavazzi L, Thiene G, Yilmaz A, Charron P, Elliott PM, European Society of Cardiology Working Group on M and Pericardial D Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European Heart Journal. 2013;34:2636–2648. doi: 10.1093/eurheartj/eht210. - DOI - PubMed
    1. Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T, Society for Cardiovascular A, Interventions, Heart Failure Society of A, Society of Thoracic S, American Heart A and American College of C 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 Assocation, 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. Journal of the American College of Cardiology. 2015;65:e7–e26. doi: 10.1016/j.jacc.2015.03.036. - DOI - PubMed
    1. Hsu KH, Chi NH, Yu HY, Wang CH, Huang SC, Wang SS, Ko WJ, Chen YS. Extracorporeal membranous oxygenation support for acute fulminant myocarditis: analysis of a single center’s experience. European Journal of Cardio-Thoracic Surgery. 2011;40:682–688. - PubMed
    1. Diddle JW, Almodovar MC, Rajagopal SK, Rycus PT, Thiagarajan RR. Extracorporeal membrane oxygenation for the support of adults with acute myocarditis. Critical Care Medicine. 2015;43:1016–1025. doi: 10.1097/CCM.0000000000000920. - DOI - PubMed
    1. Lorusso R, Centofanti P, Gelsomino S, Barili F, Di Mauro M, Orlando P, Botta L, Milazzo F, Actis Dato G, Casabona R, Casali G, Musumeci F, De Bonis M, Zangrillo A, Alfieri O, Pellegrini C, Mazzola S, Coletti G, Vizzardi E, Bianco R, Gerosa G, Massetti M, Caldaroni F, Pilato E, Pacini D, Di Bartolomeo R, Marinelli G, Sponga S, Livi U, Mauro R, Mariscalco G, Beghi C, Miceli A, Glauber M, Pappalardo F, Russo CF, Investigators G. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Annals of Thoracic Surgery. 2016;101:919–926. doi: 10.1016/j.athoracsur.2015.08.014. - DOI - PubMed

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