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Mechanical Circulatory Support —
Impella, IABP and ECMO in Hyderabad

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Dr Bhishma Chowdary cardiologist in Hyderabad
Dr Bhishma Chowdary cardiologist in Hyderabad

Mechanical Circulatory Support — Impella, IABP and ECMO in Hyderabad

When the heart is too weak to sustain adequate blood circulation — during a severe heart attack, cardiogenic shock, or a high-risk cardiac procedure — mechanical circulatory support (MCS) devices take over part or all of the heart's pumping work. At AIG Hospitals, Gachibowli, Dr. Bhishma Chowdary has hands-on expertise in the full spectrum of MCS devices: IABP, Impella, and ECMO — including complex combined support with ECPella (simultaneous ECMO and Impella) for the most critically ill patients.

At a glance — the three levels of support

IABP (Intra-Aortic Balloon Pump) Lowest level of support. Balloon in the aorta inflates and deflates with the heartbeat. Improves coronary perfusion and reduces cardiac workload. Inserted through groin artery under local anaesthesia.
Impella (percutaneous ventricular assist device) Intermediate-to-high support. Miniaturised pump placed across the aortic valve into the left ventricle. Actively pumps blood out of the weakened ventricle at up to 3.5–5 litres per minute. Most powerful catheter-based MCS.
ECMO (Extracorporeal Membrane Oxygenation) Highest level of support. Heart and lung bypass outside the body — oxygenates blood and returns it to the circulation. Used when both heart and lungs fail. Bridging therapy in the most critical situations.

What is cardiogenic shock?

Cardiogenic shock is a life-threatening condition in which the heart suddenly cannot pump enough blood to meet the body's oxygen demands. Blood pressure falls critically, organs begin to fail, and without immediate intervention the condition is fatal in the majority of cases.

The most common cause is a large acute heart attack (STEMI) that destroys a significant portion of the left ventricle. Other causes include acute decompensation of pre-existing heart failure, severe valve dysfunction, myocarditis, and post-cardiac surgery low output syndrome. Cardiogenic shock is staged using the SCAI (Society for Cardiovascular Angiography and Interventions) shock classification:

Stage A — At Risk No shock currently but high risk. Haemodynamics normal. Careful monitoring.
Stage B — Beginning Relative hypotension or tachycardia. Compensated. No evidence of hypoperfusion.
Stage C — Classic Hypotension and evidence of hypoperfusion — cold extremities, reduced urine output, altered consciousness. Classic cardiogenic shock. MCS often required.
Stage D — Deteriorating Fails to respond to initial interventions. Escalation of support required.
Stage E — Extremis Cardiac arrest — on active resuscitation or extracorporeal CPR (ECPR). ECMO typically required.

Dr. Bhishma Chowdary's ECPella experience

Dr. Bhishma Chowdary has presented original research on Stage E cardiogenic shock managed with ECPella (combined ECMO + Impella) at SCAI SHOCK — the leading international conference for cardiogenic shock management. This reflects expertise in the most advanced and technically demanding end of MCS therapy, available at AIG Hospitals Hyderabad.

IABP — Intra-Aortic Balloon Pump

How it works

The IABP consists of a long balloon mounted on a catheter. It is positioned in the descending thoracic aorta — the large artery just beyond the heart — via the femoral artery in the groin. The balloon is connected to a bedside console that inflates it with helium gas during diastole (the resting phase between heartbeats) and deflates it rapidly at the onset of systole (when the heart contracts).

This counterpulsation cycle achieves two effects simultaneously: inflation during diastole increases pressure in the aortic root, pushing more blood into the coronary arteries — improving myocardial perfusion. Deflation at the onset of systole creates a sudden drop in aortic pressure, reducing the resistance the left ventricle must pump against — reducing cardiac workload (afterload).

When is IABP used?

  • Cardiogenic shock complicating acute myocardial infarction — most classic indication
  • High-risk coronary angioplasty — prophylactic support for patients with severely reduced heart function undergoing complex PCI
  • Refractory unstable angina not responding to medications — bridge to revascularisation
  • Acute mitral regurgitation or ventricular septal defect complicating a heart attack — stabilisation before surgery
  • Low cardiac output after cardiac surgery — post-operative circulatory support
  • Bridge to Impella or ECMO when higher support is anticipated

Insertion and management

IABP insertion is performed in the cardiac catheterisation laboratory or coronary care unit under local anaesthesia. A catheter is inserted through the femoral artery in the groin using the Seldinger technique and advanced under fluoroscopic guidance to the correct position in the descending aorta. The correct position is confirmed by chest X-ray — the tip of the balloon should be 2 cm below the left subclavian artery origin. Once positioned, the balloon is connected to the console and timing is set — either triggered by the ECG R-wave or by the arterial pressure waveform. The augmentation ratio and timing are optimised by the clinical team. Anticoagulation with heparin is maintained throughout to prevent thrombus formation around the catheter.

Impella — percutaneous ventricular assist device

How it works

Impella is the world's smallest heart pump — a miniaturised axial flow pump mounted on a catheter. It is advanced through the femoral artery, across the aortic valve, and positioned with its inlet port in the left ventricle and its outlet in the ascending aorta. The pump rotates at up to 50,000 rpm, continuously drawing blood from the left ventricle and expelling it into the aorta — actively unloading the ventricle and augmenting cardiac output.

Unlike IABP which is passive and counterpulsation-based, Impella provides active, continuous forward flow — making it significantly more powerful. The Impella CP device delivers up to 3.5 litres per minute of additional cardiac output; the Impella 5.5 (surgically placed) can deliver up to 5.5 litres per minute.

Impella device variants

Impella CP Delivers up to 3.5 L/min. Inserted via 14 Fr sheath. The most widely used Impella model — suitable for both elective high-risk PCI and cardiogenic shock.
Impella CP with SmartAssist Enhanced Impella CP with optical sensor for more precise placement and automated positioning feedback.
Impella 5.5 Delivers up to 5.5 L/min. Requires surgical cutdown for access (axillary or femoral artery). Used for severe cardiogenic shock requiring maximum left ventricular unloading and longer-term support.
Impella RP Right ventricular support — placed across the pulmonary valve to support the right ventricle. Used when right ventricular failure is the dominant problem, or in combination with left-sided Impella for biventricular shock.

When is Impella used?

  • Cardiogenic shock — SCAI Stage C, D, or E — as primary MCS or escalation from IABP
  • High-risk PCI — elective prophylactic support for complex multivessel PCI, CTO-PCI, left main PCI, or unprotected left main in patients with severely reduced ejection fraction
  • Acute decompensated heart failure with haemodynamic compromise
  • Post-cardiac surgery low output syndrome
  • Bridge to recovery — supporting the ventricle while reversible causes of shock (myocarditis, stress cardiomyopathy) resolve
  • Bridge to transplantation or durable LVAD — temporary support while awaiting definitive therapy
  • ECPella — combined with ECMO for Stage E cardiogenic shock with cardiac arrest

Large-bore access and closure

Impella CP and 5.5 require large-bore arterial access (13–14 Fr and above). Dr. Bhishma Chowdary uses ultrasound-guided femoral artery puncture for precise access — reducing the risk of high or low stick complications that increase bleeding risk with large-bore sheaths. Vascular closure after Impella removal is performed with dedicated large-bore closure devices (Perclose ProGlide or MANTA) — a technique requiring specific training and experience to execute safely.

ECMO — Extracorporeal Membrane Oxygenation

What is ECMO?

ECMO is the most advanced form of temporary cardiorespiratory support available. A circuit of tubing drains blood from the body, passes it through an artificial lung (oxygenator) that adds oxygen and removes carbon dioxide, then a pump returns the oxygenated blood to the circulation. ECMO essentially replaces both heart and lung function simultaneously.

VA-ECMO vs VV-ECMO

VA-ECMO (Veno-Arterial) Used for cardiac failure. Blood is drained from a large vein (femoral vein) and returned to a large artery (femoral artery). Supports both cardiac output and oxygenation. Used in cardiogenic shock, cardiac arrest, and high-risk procedures.
VV-ECMO (Veno-Venous) Used for isolated respiratory failure. Blood drained and returned to the venous circulation only — no cardiac support. Used for severe ARDS, respiratory failure. Not used for cardiac shock alone.

When is VA-ECMO used in cardiac patients?

  • SCAI Stage E cardiogenic shock — cardiac arrest or peri-arrest, refractory to standard resuscitation
  • Extracorporeal CPR (ECPR) — ECMO initiated during active cardiac arrest to restore circulation while the underlying cause is treated
  • Refractory cardiogenic shock not responding to Impella or IABP alone
  • Massive pulmonary embolism causing haemodynamic collapse
  • Severe acute myocarditis with cardiogenic shock
  • Bridge to heart transplantation or durable LVAD implantation
  • High-risk electrophysiology procedures or ablation in patients with severely compromised cardiac function

ECPella — combined ECMO and Impella

In the most severe cases of cardiogenic shock — particularly SCAI Stage E — ECMO alone may sustain systemic circulation but actually increases left ventricular afterload (the pressure the damaged heart must pump against), potentially worsening LV distension and impairing myocardial recovery. The solution is ECPella: simultaneous ECMO support combined with Impella left ventricular unloading. This combination allows maximum systemic support from ECMO while simultaneously decompressing the failing left ventricle with Impella — creating optimal conditions for myocardial recovery. ECPella is technically demanding, requires specific expertise in managing two simultaneous devices with opposing haemodynamic effects, and is available at only a small number of centres in South India.

Available at AIG Hospitals, Hyderabad

Dr. Bhishma Chowdary has presented original research on ECPella for Stage E cardiogenic shock at SCAI SHOCK — the premier international cardiogenic shock conference. ECPella is available at AIG Hospitals, Gachibowli with round-the-clock capability for the most critically ill cardiac patients.

Comparing IABP, Impella and ECMO

Cardiac output augmentation IABP: 0.3–0.5 L/min. Impella CP: up to 3.5 L/min. ECMO: 3–5+ L/min.
LV unloading IABP: Indirect (afterload reduction). Impella: Direct (active LV decompression). ECMO (VA alone): Increases LV afterload — worsens unless combined with Impella.
Oxygenation support IABP: None. Impella: None. ECMO: Full oxygenation support.
Access IABP: 7–8 Fr femoral artery. Impella CP: 14 Fr femoral artery. ECMO: 15–21 Fr femoral vein + 15–17 Fr femoral artery.
Insertion complexity IABP: Simple. Impella: Moderate — requires specific training. ECMO: Complex — team approach.
Duration IABP: Days to weeks. Impella: Days to weeks. ECMO: Days to months.
Best indication IABP: Moderate shock, high-risk PCI. Impella: Cardiogenic shock, high-risk PCI. ECMO: Cardiac arrest, severe biventricular failure.

Frequently asked questions

What is the difference between IABP, Impella and ECMO in simple terms?

Think of them as three tiers of emergency heart support. IABP is the simplest — a balloon that helps the heart's own pumping by improving blood flow to the coronary arteries and reducing its workload, but it cannot replace lost pumping function. Impella is a miniaturised pump placed inside the heart that actively moves blood for the weakened ventricle — much more powerful than IABP. ECMO is the most advanced — it takes blood out of the body, oxygenates it through an artificial lung, and pumps it back, essentially replacing both heart and lung function when both have failed.

Will my family member be conscious during Impella or ECMO support?

It depends on the clinical situation. Patients on IABP are often awake and communicating. Patients on Impella may be awake or sedated depending on the severity of their condition. ECMO patients are typically heavily sedated in an ICU setting, particularly in the acute phase, to allow the heart and lungs to rest and recover. As the condition improves and support is weaned, sedation is reduced and patients progressively become more alert. The team will update families regularly on the patient's status and level of consciousness.

How long is a patient on mechanical circulatory support?

Duration varies enormously. IABP or Impella used prophylactically during a planned procedure may be removed the same day. In cardiogenic shock, support typically continues for 3 to 7 days while the heart recovers from a heart attack or myocarditis. If the heart does not recover adequately, longer-term options including a durable ventricular assist device (LVAD) or cardiac transplantation are discussed. ECMO as a bridge to transplantation or LVAD may continue for weeks to months in selected cases.

What are the main risks of mechanical circulatory support?

All MCS devices carry risks related to vascular access (bleeding, limb ischaemia), device-related complications (haemolysis with Impella, thrombosis), and infection with prolonged use. ECMO carries additional risks including neurological events and complications related to the circuit. These risks are carefully weighed against the expected benefit — in cardiogenic shock, the risk of not providing MCS is death, which fundamentally changes the risk-benefit calculation. Dr. Bhishma Chowdary and the ICU team monitor for and manage these complications proactively throughout the period of support.

Is mechanical circulatory support available 24/7 at AIG Hospitals?

Yes. AIG Hospitals, Gachibowli has round-the-clock MCS capability — IABP, Impella, and ECMO are all available at any hour. The cardiac catheterisation laboratory is available 24/7 for emergency primary angioplasty combined with MCS insertion in cardiogenic shock. This continuous availability is a critical requirement for managing the most severe cardiac emergencies and is not available at all hospitals in Hyderabad.

Can Impella be used alongside angioplasty for a high-risk procedure?

Yes — this is called protected PCI or Impella-supported high-risk PCI. When a patient with severely reduced heart function (ejection fraction below 35%) needs complex coronary angioplasty — involving the last remaining coronary artery, left main artery, or multiple vessels — the procedure carries a significant risk of haemodynamic compromise during balloon inflation or stenting. Impella is inserted before the angioplasty begins, providing continuous cardiac output support throughout, and is removed after the procedure is completed. This allows safe performance of procedures that would be prohibitively risky without haemodynamic support.

Why choose Dr. Bhishma Chowdary for MCS at AIG Hospitals, Hyderabad?

  • Hands-on expertise in IABP, Impella CP, and VA-ECMO insertion and management
  • ECPella experience — combined ECMO and Impella for Stage E cardiogenic shock — presented at SCAI SHOCK international conference
  • Large-bore ultrasound-guided vascular access and closure expertise (Perclose, MANTA) — essential for safe Impella insertion and removal
  • Full cardiac ICU at AIG Hospitals with continuous haemodynamic monitoring and device management capability
  • 24/7 MCS availability — all three devices available round the clock for emergency cardiac cases
  • Integrated team approach — interventional cardiologist, cardiac intensivist, and cardiac surgeon collaborating on complex MCS cases
  • Experience with Impella-supported high-risk PCI — enabling safe revascularisation in patients with severely reduced heart function
  • Fluent consultations in English, Hindi, and Telugu

Emergency and referral contact

For emergency referrals of cardiogenic shock patients requiring MCS, or for planned high-risk PCI requiring Impella support, contact AIG Hospitals directly:

Call: +91-9000352998

Email: bhishmachowdary@gmail.com

Location: AIG Hospitals, Gachibowli, Hyderabad — 500032

Clinic hours: Monday to Saturday, 10:00 AM to 4:00 PM

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