Left Ventricular Unloading With the Impella Pump in Adolescents on Venoarterial Extracorporeal Membrane Oxygenation

Combining the Impella device and extracorporeal membrane oxygenation (ECMO) support has been suggested to counteract the left ventricular (LV) afterload seen with ECMO, prevent complications during venoarterial-ECMO (VA-ECMO), and facilitate weaning from VA-ECMO. While this technique has been successfully utilized in adults, there are limited efficacy data in patients under 18 years of age.Between July 2016 and April 2024, eight pediatric patients, who were 13 to 18 years of age and weighing 40 to 59 kg, underwent VA-ECMO support with Impella 2.5 or CP implantations at our institution. All patients were hemodynamically unstable at presentation (INTERMACS 1).The indications for implantation were heart failure secondary to myocarditis (four patients), rejection of a prior orthotopic heart transplant (one patient), heart failure after repair of transposition of the great arteries (one patient), metabolic cardiomyopathy (one patient), and arrhythmia-induced cardiomyopathy (one patient). The VA-ECMO cannulation was performed via neck vessels in six patients and groin vessels in two. The median duration of Impella support was eight days (range, 2-20 days). Our practice is to wean the patient off ECMO first while ensuring support in the early stages of ECMO removal with the Impella device. The median duration of ECMO support was seven days (range, 4-32 days). One patient was bridged to transplant, one patient received a HeartMate3, five patients recovered myocardial function and were weaned off mechanical support, and one patient died while on support.In adolescent acute heart failure, a short ECMO run with LV unloading provided by the Impella device is a promising strategy that might facilitate rapid recovery of myocardial function in hemodynamically unstable adolescents.