AIMS: Patients with acute decompensated advanced heart failure requiring left ventricular assist device (LVAD) implantation often experience progressive cardiac function deterioration, negatively impacting surgical outcomes. This study aimed to assess the efficacy of different microaxial flow pump (mAFP) support devices (Impella®) in achieving optimal left ventricular unloading for preconditioning and facilitating definitive treatment in this high-risk patient cohort. METHODS AND RESULTS: A retrospective analysis was conducted across 19 high-volume European centres. The study population included patients transitioning from temporary to durable circulatory support over a 7.5-year period, with a median follow-up of 1 year. Patients were categorized based on mAFP support capacity: those receiving high-flow support (>5 L/min, '5+') and those with lower-flow support (3.5 L/min, 'CP'). Patients who were initially treated with CP but subsequently upgraded to 5+ support were classified in the 5+ group. Demographic and clinical characteristics, mobilization, right heart function, and organ dysfunction outcomes were analysed. A total of 339 patients received preoperative mAFP support prior to LVAD implantation. The 5+ group comprised 247 patients (73%), including 38 patients who were upgraded from CP, while the CP group included 92 patients (27%). Baseline demographic and clinical characteristics were comparable between groups, except for mobilization status, which showed significant differences (P < 0.001). Patients in the 5+ group achieved higher rates of full and partial mobilization compared to the CP group. Extracorporeal life support (ECLS) was more frequently required in the CP group than in the 5+ group (40.5% vs. 33.8%; P < 0.001). Additionally, right ventricular assist device (RVAD) implantation was significantly more common in the CP group (29.2% vs. 18.2%; P = 0.026). Patients in the 5+ group demonstrated greater reductions in both vasoactive inotropic scores (P = 0.006) and inotropic scores (P = 0.008). Furthermore, liver dysfunction (P = 0.016), renal failure (P = 0.041), and the need for dialysis (P = 0.013) were significantly more prevalent in the CP group. There were no significant differences between the two groups in terms of LVAD operative duration (P = 0.637) or cardiopulmonary bypass time (P = 0.408). CONCLUSIONS: High-flow mAFP devices (+5) provided superior haemodynamic support, enhanced left ventricular unloading, and reduced dependence on catecholamines compared to lower-flow CP devices. These improvements were associated with lower rates of right ventricular failure, renal dysfunction, and liver injury. However, no statistically significant difference was observed between mAFP groups regarding 30-day mortality rates.

2nd Department of Internal Medicine Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine Charles University Prague Czech Republic

Deparment of Cardiac Surgery IRCCS Bologna St Orsola University Hospital Bologna Italy

Department of Anesthesia and Intensive Care IRCCS San Raffaele Scientific Institute Milan Italy

Department of Cardiac and Vascular Surgery University Medical Center of the Johannes Gutenberg University Mainz Mainz Germany

Department of Cardiac Surgery Heidelberg University Hospital Heidelberg Germany

Department of Cardiac Surgery Leipzig Heart Center Leipzig Germany

Department of Cardiac Surgery Schüchtermann Clinic Bad Rothenfelde Germany

Department of Cardiac Surgery University Hospitals Leuven Leuven Belgium

Department of Cardiac Surgery University of Essen Essen Germany

Department of Cardiology University Medical Center Utrecht Utrecht Netherlands

Department of Cardiothoracic and Vascular Surgery Deutsches Herzzentrum der Charité Berlin Germany

Department of Cardiothoracic Surgery Jena University Hospital Jena Germany

Department of Cardiothoracic Surgery Rigshospitalet Copenhagen Denmark

Department of Cardiothoracic Surgery University Hospital Cologne Cologne Germany

Department of Cardiothoracic Surgery University Hospital RTWH Aachen Aachen Germany

Department of Cardiovascular Surgery Charité Universitätsmedizin Berlin Berlin Germany

Department of Cardiovascular Surgery University Heart Center Hamburg Hamburg Germany

Department of Cardiovascular Surgery University Hospital Duesseldorf Duesseldorf Germany

Department of Cardiovascular Surgery University Hospital Schleswig Holstein Kiel Germany

Department of Surgery Division of Cardiac Surgery Medical University of Vienna Vienna Austria

Department of Surgical Sciences University of Turin Turin Italy

DZHK partner site Berlin Berlin Germany

Heart and Diabetes Center North Rhine Westphalia Bad Oeynhausen Germany

Institute of Clinical and Experimental Medicine Prague Czech Republic

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