Cost savings and outcomes with stepdown versus ICU management of patients with cardiogenic shock supported by Impella 5.5 percutaneous left ventricular assist devices

Utilization of surgically implanted Impella 5.5 percutaneous left ventricular assist devices (LVADs) is increasing. Patients supported by Impella 5.5 are typically managed in the ICU. At advanced heart failure centers, patients are often supported by Impella 5.5 for extended periods of time while awaiting destination therapy. This creates strain on ICU beds and increases hospitalization costs.

We aimed to assess clinical outcomes and the financial impact of transferring clinically stable patients with Impella 5.5 support from the ICU to a specialized stepdown unit.

In January 2023, patients with Impella 5.5 at our institution who were deemed clinically stable were eligible for transfer to a stepdown unit after at least 24 hours in the ICU post implant. Clinical stability was defined as the absence of significant bleeding, device/console issues, or hypoperfusion. Baseline characteristics, in-hospital outcomes, and device-related adverse events were collected retrospectively and adjudicated by the multidisciplinary cardiogenic shock team. Cost analysis was performed using hospital facility fee data, excluding all other charges such as procedural, diagnostic, professional, and medical fees.

Between Jan 1, 2023 and Mar 31, 2024, a total of 64 patients with Impella 5.5 were managed at our institution. Of these, 42 (66%) were deemed clinically stable for transfer to stepdown. The median (IQR) duration of Impella 5.5 management on stepdown was 11 (7, 21) days (range 1-82), totaling 733 Impella-days.

Stepdown patients with Impella 5.5 had a median age of 60 (50, 63) years, were mostly male (71%) with acute on chronic HF (97.6%) and presented with Stage C (52%) or D (43%) shock. While 43% had baseline kidney disease, none required renal replacement.

Hospital facility fees for stepdown-level care were 61% ($1,222 US dollars) lower per day than ICU level care (Figure 1). Based on a total of 733 Impella-days, the total cost savings associated with caring for patients with Impella 5.5 on stepdown was $895,726 US dollars. At an average of 586 Impella-days per year on stepdown, the yearly cost savings was $716,092 US dollars/year.

A total of 12 adverse events occurred in Impella 5.5 patients while on stepdown. These included clinically significant bleeding (1 event), hemolysis (5 events), stroke/TIA (2 events), vascular injury (3 events), and heparin induced thrombocytopenia (1 event) (Figure 2). There were no episodes of bacteremia while on stepdown. Ultimately, 28 (67%) patients underwent heart transplant and 10 (24%) underwent LVAD implant during the hospitalization. One patient died during their hospital course, in whom care was withdrawn due to lack of a destination option.

Transfer of select, clinically stable patients supported by Impella 5.5 to a stepdown unit resulted in a substantial cost savings with acceptably low rates of adverse events while on stepdown.

Cost savings summary