Abstract 4366794: Comparable Outcomes in Direct Impella Use Versus Intra-Aortic Balloon Pump-to-Impella Escalation Strategy in Cardiogenic Shock

Introduction: Impella and IABP are widely used temporary mechanical circulatory support (tMCS) devices in cardiogenic shock (CS). While Impella can be used as the initial support device or after IABP as an escalation strategy, comparative data on these two strategies remain limited. Hypothesis: We hypothesized that in-hospital mortality would be similar between direct Impella use and stepwise escalation from IABP to Impella. Methods: Using ICD-10 codes in the 2016–2022 National Inpatient Sample database, we identified patients with a primary diagnosis of CS who received Impella support. Patients were divided into two groups: direct Impella use and escalation from IABP to Impella. Propensity score matching was performed to adjust for patient and hospital demographics, comorbidities, and complications. The primary outcome was in-hospital mortality, with secondary outcomes including length of stay (LOS) and total hospital charges. A sensitivity analysis compared outcomes in patients receiving Impella 5.0/LD/5.5 directly versus after IABP escalation. Results: Among 107,007 patients requiring Impella support, 700 patients (0.65%) underwent IABP-to-Impella escalation. Before matching, mortality was similar between groups (39.0% vs. 39.4%, p=0.86), while the direct Impella group had significantly shorter LOS (11.4±13.97 vs 19.28±20.70 days, p<.001) and lower total hospital charges ($441,236 vs $726,021, p<.001). After propensity score matching, these differences persisted: the direct Impella group had shorter LOS (13.17±17.21 vs. 19.22±20.70 days, p<0.001) and lower total charges ($478,526 vs. $725,276, p<0.001) with no significant difference in mortality. Sensitivity analysis of Impella 5.0/LD/5.5 showed similar trends, with shorter LOS (39.01±28.32 vs. 47.16±29.65 days, p) and lower total charges ($1,331,529 vs. $1,661,216, p=.047) in the direct Impella group after matching. Conclusion: In this national real-world cohort, direct Impella use and IABP-to-Impella escalation had comparable in-hospital mortality among CS patients. However, direct Impella use was linked to shorter hospital stays and lower total costs, highlighting potential benefits in resource efficiency and utilization.