Comparative Outcomes of Direct Impella Use vs. Intra-Aortic Balloon Pump (IABP)-to- Impella Escalation Strategy in Cardiogenic Shock: Insights from the National Inpatient Sample

BACKGROUND: Impella and IABP are widely used temporary mechanical circulatory support devices in cardiogenic shock (CS). While the Impella is used as an initial support or after IABP as escalation strategy, comparative data on these two strategies remains limited. METHODS: Using ICD-10 codes in the 2016-2022National Inpatient Sample (NIS) database, we identified patients with primary diagnosis of CS who received Impella support and divided in two groups: direct Impella use and escalation from IABP to Impella. Propensity score matching was performed to adjust for confounding. RESULTS: Among 107,007 patients were included, 700 (6.5%) underwent IABP-to-Impella escalation strategy. Before matching, the direct Impella use had significantly shorter length-of-stay (LOS) 11.4±13.97 vs. 19.28±20.70 days, P <0.001), lower total hospital charges ($441,236 vs. $726,021, P <0.001) and fewer transfusions (14.8% vs. 20.6%, P <0.001), while the escalation Impella use after IABP had higher rates of durable left ventricular assist device (LVAD) implantation (7.9% vs. 2.2%, P <0.001) and rates of orthotopic heart transplant (OHT) (5.0% vs. 1.2%, P <0.001). After matching, the direct Impella group still had shorter LOS (13.77±17.21 vs 19.22±20.70 days, P <0.001), lower total costs ($478,526 vs. $725,276, P <0.001), and fewer transfusions (1.9% vs. 4.9%, P =0.026), while escalation Impella use after IABP still had higher rates of LVAD implantation (7.7% vs. 3.0%, P <0.001) and OHT (4.9% vs. 1.9%, P =0.003). CONCLUSIONS: In cardiogenic shock, direct and escalation Impella use were associated with similar in-hospital mortality, but direct use was linked to shorter hospital stays and lower costs, highlighting potential benefits in resource utilization and efficiency.