Mechanical Support Before Shock: A Surgeon’s Strategy for Impella 5.5 and ECMO

Mechanical circulatory support in cardiac surgery is not just a bailout strategy- it can be a way to prevent the shock cascade before it becomes difficult to reverse. In this MurmurMD discussion, Dr. Chris Brown speaks with Dr. Robert Farivar about how he uses mechanical support before, during, and after cardiac surgery. Dr. Farivar explains why the EACTS-STS guidance reinforces a practice pattern he has followed for years: identify patients early, intervene before low-output states spiral, and avoid relying too long on escalating inotropes when mechanical support may better protect end-organ function. The conversation compares balloon pump support, Impella CP, Impella 5.5, ECMO, and biventricular Impella strategies. It also goes deep on Dr. Farivar’s direct aortic Impella 5.5 technique, when axillary placement makes sense, how he manages support during surgery, and why right-sided recovery often requires patience. KEY TOPICS • Preventing shock before the cascade starts • Balloon pump limitations and select use cases • Impella CP vs Impella 5.5 support levels • Impella 5.5 vs ECMO tradeoffs • ECMO venting, limb, bleeding, and Harlequin concerns • Direct aortic Impella 5.5 placement technique • Axillary Impella stability and device migration risk • EF less than 35% in major cardiac surgery • Rising lactate as a low-output warning sign • Avoiding prolonged inotrope escalation • Escalating from CP to 5.5 before surgery • Managing Impella 5.5 during cardiopulmonary bypass • Echo-guided weaning and myocardial recovery • Biventricular Impella support and RV recovery timeline 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA CHAPTERS 00:00 – Introduction: mechanical support in surgery 01:03 – Preventing shock before it spirals 02:40 – Balloon pump limitations 04:04 – Impella CP, Impella 5.5, and ECMO 05:26 – Impella 5.5 vs ECMO tradeoffs 08:01 – Impella 5.5 placement options 08:41 – Direct aortic Impella 5.5 technique 11:07 – Who should get perioperative MCS? 13:20 – Rising lactate and limits of inotropes 15:39 – Rescue support when patients cannot come off bypass 17:24 – Direct aortic vs axillary stability 20:59 – Pre-surgical shock and CP-to-5.5 escalation 23:12 – Managing Impella 5.5 during surgery 24:53 – Echo assessment, pulsatility, and weaning support 27:51 – Biventricular Impella support and RV recovery 30:19 – Closing thoughts #MechanicalCirculatorySupport #Impella55 #Impella #ECMO #CardiacSurgery #CTsurgery #CardiogenicShock #HeartFailure #MCS #ShockPrevention #MurmurMD