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Impella vs. IABP in Non-emergent High-Risk PCI: Outcomes and LVEF Recovery from a Large US EHR Study
Jason R Wollmuth1, Aditya S Bharadwaj2, Nudrat Noor3
1Providence Heart Institute, 9427 SW Barnes Rd Ste 495, Portland, OR, 97225, USA. jason.wollmuth@providence.org.
Insights
In high-risk percutaneous coronary intervention (HR-PCI), Impella support demonstrated lower mortality and reduced acute kidney injury compared to intra-aortic balloon counterpulsation (IABP). This study also found Impella associated with greater left ventricular ejection fraction (LVEF) recovery.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- High-risk percutaneous coronary intervention (HR-PCI) treats complex coronary disease, often with limited surgical options.
- Mechanical circulatory support (MCS) may mitigate procedural risks and aid complete revascularization.
- Comparative data on outcomes and left ventricular ejection fraction (LVEF) recovery with different MCS devices are scarce.
Purpose of the Study:
- To evaluate outcomes and LVEF recovery in contemporary, real-world HR-PCI patients.
- To compare Impella (continuous, forward high-flow pump) with intra-aortic balloon counterpulsation (IABP) in non-emergent HR-PCI.
- To test the hypothesis that Impella benefits extend to non-protocolized datasets.
Main Methods:
- Synthesized an MCS-specific cohort from electronic health records (2017-2025).
- Included adults undergoing non-emergent HR-PCI with Impella or IABP support, excluding emergent cases and specific comorbidities.
- Utilized propensity score matching (1:1) and assessed mortality, adverse events (cd-AKI, cd-bleeding), and LVEF change within one year.
Main Results:
- After propensity score matching, Impella use was linked to lower 30-day (12.7% vs. 16.6%) and 90-day (15.2% vs. 19.6%) all-cause mortality.
- Impella support was associated with reduced code-derived acute kidney injury (cd-AKI) (15.7% vs. 20.3%).
- Both groups showed LVEF improvement, with a greater increase observed with Impella (+7%) compared to IABP (+3%) in matched subgroups.
Conclusions:
- In contemporary, non-emergent HR-PCI, Impella use showed improved survival and reduced adverse events versus IABP.
- Impella support was associated with greater LVEF recovery compared to IABP.
- Findings support the use of Impella in selected HR-PCI patients within real-world settings.
Introduction:
High-risk percutaneous coronary intervention (HR-PCI) involves patients with complex coronary disease, adverse hemodynamics, and/or severe comorbidities who are often ineligible for surgery. Mechanical circulatory support (MCS) may reduce procedural risk and facilitate complete revascularization. However, comparative data on outcomes and left ventricular ejection fraction (LVEF) recovery are limited. We hypothesized that the benefits of MCS-supported PCI observed in prior studies would extend to contemporary, real-world, non-protocolized all-comer datasets, where outcomes and LVEF recovery in patients undergoing non-emergent Impella- or intra-aortic balloon counterpulsation (IABP)-supported HR-PCI can be evaluated.
Methods:
We synthesized an MCS-specific cohort using de-identified electronic health record data (2017-2025). Adults undergoing non-emergent HR-PCI supported with cardiac unloading via a continuous, forward high-flow pump (Impella) or IABP were included. Admissions with emergent status, right heart failure, cardiogenic shock, or ST-elevation myocardial infarction, or those undergoing coronary artery bypass grafting, were excluded. Propensity score matching (1:1) adjusting for baseline differences was performed. Outcomes included all-cause mortality (7, 30, and 90 days) and 30-day, medical code-derived (cd) adverse events (acute kidney injury [cd-AKI] and cd-bleeding requiring transfusion). LVEF change within 1 year was assessed in a predefined subgroup.
Results:
Before matching, patients supported with Impella had more comorbidities, lower baseline LVEF, and more complex procedural characteristics than IABP-supported patients. After matching, baseline characteristics were balanced. Impella was associated with lower all-cause mortality at 30 days (12.7% vs. 16.6%) and 90 days (15.2% vs. 19.6%), and reduced cd-AKI (15.7% vs. 20.3%). In patients matched for baseline LVEF values and collection timing, both groups demonstrated LVEF improvement (+ 7% for Impella; + 3% for IABP).
Conclusion:
In contemporary, non-protocolized, non-emergent HR-PCI, the use of Impella was associated with improved outcomes and greater LVEF recovery compared to IABP.
