Percutaneous Circulatory Assist Devices for High-Risk Coronary Intervention

Impella versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention

The benefit of mechanical circulatory support (MCS) with Impella (Abiomed, Inc, Danvers, MA) for patients undergoing nonemergent, high-risk percutaneous coronary intervention (HR-PCI) is unclear and currently the subject of a large randomized clinical trial (RCT), PROTECT IV. While contemporary registry data from PROTECT III demonstrated improvement of outcomes with Impella when compared with historical data (PROTECT II), there is lack of direct comparison to the HR-PCI cohort that did not receive Impella support. We retrospectively identified patients from our institution meeting PROTECT III inclusion criteria (left ventricular ejection fraction [LVEF] <35% with unprotected left main or last remaining vessel or LVEF <30% undergoing multivessel PCI), and compared this group (NonIMP) to the published outcomes data from the PROTECT III registry (IMP). Baseline differences were balanced using inverse propensity weighting (IPW). The co-primary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. Secondary outcomes included in-hospital post-PCI complications. We identified 284 high-risk patients who did not receive Impella support; 200 patients had 90-day event ascertainment and were included in IPW analysis, with 504 patients in the IMP group. After calibration, few residual differences remained; patients in the NonIMP group were older (73.4 vs. 69.3, p <0.001) with higher prevalence of coronary artery bypass grafting (65.0% vs. 13.7%, p <0.001). Unprotected left main intervention was performed in 43% of patients in both groups. The primary outcome was not different in-hospital (3.0% vs. 4.8%, p = 0.403), but lower in the NonIMP group at 90 days (7.5% vs. 13.8%, p = 0.033). Peri-procedural vascular complications, bleeding, and transfusion rates were not different between groups. However, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs. 5.4%, p = 0.023). Under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella supported HR-PCI cohort demonstrated similar MACE in-hospital but lower MACE at 90 days. There was no signal for peri-procedural harm with Impella use. These results do not support routine usage of Impella for HR-PCI patients. Careful patient selection is critical until a large RCT demonstrates benefits in a broad HR-PCI population.

Correlates of Hemodynamic Instability During Non-Emergent Percutaneous Coronary Intervention: Refining High-Risk Criteria for Utilizing Mechanical Circulatory Support

BACKGROUND

Previous studies using high-risk criteria to select patients for mechanical circulatory support (MCS) during percutaneous coronary intervention (PCI) have not consistently shown a benefit in reducing adverse outcomes. Identifying correlates for intra-procedural hemodynamic instability (HI) may improve patient selection for MCS.

METHODS

Consecutive, hemodynamically stable patients undergoing non-emergent PCI between 2018 and 2022 were reviewed. High-risk patients, defined by left ventricular ejection fraction ≤ 35% with unprotected left main intervention or LVEF ≤ 35% with 3-vessel disease, were compared to the non-high-risk patients. The primary outcome was HI during PCI, a composite outcome defined by the occurrence of death, cardiac arrest, emergent MCS, or the need for sustained vasopressor support.

RESULTS

A total of 278 high-risk patients were compared to 2854 non-high-risk patients. The high-risk group was older with more comorbidities and poorer left ventricular ejection fraction (24.7% vs. 51.5%). The occurrence of HI was overall low but occurred more frequently in high-risk patients (4.3% vs. 2.2%, p = 0.025), mostly driven by sustained vasopressor need (75% vs. 66%, p = 0.023). Post-procedural adverse clinical events were more common in the high-risk group, including death (4.7% vs. 0.7%, p < 0.001). A predictive model for intraprocedural HI included: ejection fraction ≤ 25%, left main intervention, and atherectomy (AUC = 0.703), while 3-vessel disease, age and other clinical comorbidities were not strongly associated with HI.

CONCLUSION

The rate of HI during contemporary, non-emergent PCI is very low. While Traditional high-risk PCI criteria are associated with HI, prediction may be improved by including only very low EF, left main intervention and atherectomy. Further studies are needed to evaluate whether utilizing risk factors for HI could be a more effective strategy for selecting patients of MCS during PCI.

Percutaneous coronary intervention for calcified and resistant lesions

Relevant calcified coronary artery disease (CCAD) may be present in around 20% of patients undergoing percutaneous coronary interventions, and it is known to add procedural challenges and risks. Careful patient selection and specific expertise in multimodality imaging and plaque modification techniques are required to plan and adopt the most appropriate therapeutic strategy. This review aims to present the contemporary clinical approach and procedural planning for CCAD patients, describing the available tools and strategies in view of the most recent scientific evidence.

The Impact of Age in Patients Undergoing Impella-Assisted Percutaneous Coronary Interventions

BACKGROUND

Short-term percutaneous mechanical circulatory support (MCS) devices provide hemodynamic support in cardiogenic shock or during high-risk percutaneous coronary intervention (PCI).

AIMS

To assess the impact of age on the clinical and angiographic characteristics and in-hospital outcomes of all patients undergoing PCI with the Impella MCS.

METHODS

Data on all patients that underwent PCI with an Impella was divided into three groups according to age: < 65, 65 to < 75 years, and ≥ 75 years. In-hospital mortality, stroke, and major bleeding complications were assessed.

RESULTS

Between 2010 and 2018, 245 patients underwent PCI with Impella support. Almost half of all patients were < 65 years old and 32% were ≥ 75 year old. Clinical characteristics varied significantly among the three groups. Almost half of younger patients were in the midst of an ST-elevation myocardial infarction (STEMI) compared with 9% of patients ≥ 75 years (p < 0.0001). Furthermore, 57% of younger patients were in cardiogenic shock, compared with 21% of those ≥ 75 years (p = 0.002). In-hospital mortality was highest in the 65 to < 75 years group (17%) compared with 9% and 10% in the < 65 and ≥ 75-year-olds groups, respectively. Major bleeding complications were not significantly different among the three age groups. Multivariable analysis for in-hospital mortality showed that STEMI on presentation and ages 65 to < 75 years compared to those < 65 years were associated with an increased odds of in-hospital death.

CONCLUSION

Clinical characteristics and indications for Impella MCS use in patients undergoing PCI varied significantly according to age. However, in-hospital outcomes were not significantly different among the three groups.

Hemodynamic Evaluation of Intra-Aortic Dual-Balloon Pump Based on Fluid-Structure Interaction

The intra-aortic balloon pump (IABP) is a widely-used mechanical circulatory support device that enhances hemodynamics in patients with heart conditions. Although the IABP is a common clinical tool, its effectiveness in enhancing outcomes for patients with acute myocardial infarction and cardiogenic shock remains disputed. This study aimed to assess the effectiveness of intra-aortic dual-balloon pump (IADBP) and its impact on aortic hemodynamics compared with an IABP. Three-dimensional finite element models were constructed for the aorta, IABP, and IADBP, followed by numerical simulation using the fluid-structure coupling (FSI) method. Three simulations were conducted: Heart failure patients without assistive devices (Case A), those with IABP (Case B), and those with IADBP (Case C). The study assessed the IADBP's hemodynamic effects by measuring aortic branch blood flow, left ventricular afterload, aortic wall stress, and wall shear stress. IADBP outperformed IABP in enhancing blood flow to the coronary arteries, upper limbs, and brain vessels (left and right coronary arteries: 0.88 vs. 1.27, 1.27 vs. 1.99 mL/beat; brachiocephalic artery, left common carotid artery, and left subclavian artery: 6.08 vs. 12.39, 2.48 vs. 4.97, 2.31 vs. 5.08 mL/beat). IADBP also demonstrated superior performance in counterpulsation pressure and left ventricular ejection (counterpulsation phase: 97.41 mmHg vs. 110.03 mmHg; ventricular unloading phase: 72.21 mmHg vs. 66.46 mmHg). The use of IADBP elevates stress on the aortic wall and wall shear stress, potentially affecting vascular health. IADBP effectively addresses upper limb and cerebral hypoperfusion issues associated with IABP, demonstrating superior performance in enhancing counterpulsation pressure and left ventricular ejection. Despite potential vascular biomechanical effects, IADBP provide a promising clinical treatment option. Further studies are needed to refine IADBP 's design and evaluate its long-term clinical efficacy.

Comparison of Four Intensive Care Scores in Predicting Outcomes After Venoarterial Extracorporeal Membrane Oxygenation: A Single-center Retrospective Study

OBJECTIVE

To assess the capability of the Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, Cardiac Surgery Score (CASUS), and Survival After VA-ECMO (SAVE) in predicting outcomes among a cohort of patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO).

DESIGN

This is an observational retrospective study of 142 patients admitted to the cardiothoracic intensive care unit (CTICU) after undergoing VA-ECMO insertion.

SETTING

CTICU of a tertiary care center.

PARTICIPANTS

All patients admitted to the CTICU for a minimum of 24 hours, post-VA-ECMO insertion, between 2015 and 2022.

INTERVENTIONS

Review of electronic patient records.

MEASUREMENTS AND RESULTS

Scores for APACHE-II, SOFA, and CASUS were calculated 24 hours after intensive care units (ICU) admission. The SAVE score was computed from the last available patient details within 24 hours of ECMO insertion. Relevant demographic, clinical, and laboratory data for the study was retrieved from electronic patient records. Pre-ECMO serum levels of lactates and creatinine were significantly associated with mortality. Lower ECMO flow rates at 4 and 12 hours post-ECMO cannulation were significantly correlated with survival to discharge. The development of arrhythmias, acute kidney injury, and the need for continuous renal replacement therapy while on ECMO were significantly associated with mortality. The APACHE-II, SOFA, and CASUS scores, calculated at 24 hours of ICU admission, were significantly higher amongst nonsurvivors. Following risk score categorization using receiver operating characteristic curve analysis, it was found that APACHE-II, SOFA, and CASUS scores calculated 24 hours post-ICU admission after ECMO insertion demonstrated moderate predictive ability for mortality. In contrast, the SAVE score failed to predict mortality. APACHE-II >27 (area under the curve = 0.66), calculated 24 hours post-ICU admission after ECMO insertion, showed the greatest predictive ability for mortality. Multivariate logistic regression analysis of the four scores showed that APACHE-II >27 and SOFA >14, calculated 24 hours post-ICU admission after ECMO insertion, were independently significantly predictive of mortality.

CONCLUSION

The APACHE-II, SOFA, and CASUS, calculated at 24 hours of ICU admission, were significantly higher among nonsurvivors compared with survivors. The APACHE-II demonstrated the highest mortality predictive ability. APACHE-II scores of 27 or above and SOFA scores of 14 or above at 24 hours of ICU admission after ECMO cannulation can predict mortality and assist physicians in decision-making.

Impella Versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention

The benefit of mechanical circulatory support with Impella (Abiomed, Inc., Danvers, Massachusetts) for high-risk percutaneous coronary intervention (HR-PCI) is uncertain. PROTECT III registry data showed improved outcomes with Impella compared with historical data (PROTECT II) but lack a direct comparison with the HR-PCI cohort without Impella support. We retrospectively identified patients meeting the PROTECT III inclusion criteria for HR-PCI and compared this group (non-Impella cohort [NonIMP]) with the outcomes data from the PROTECT III registry (Impella cohort). Baseline differences were balanced using inverse propensity weighting. The coprimary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. A total of 283 patients at great risk did not receive Impella support; 200 patients had 90-day event ascertainment and were included in the inverse propensity weighting analysis and compared with 504 patients in the Impella cohort group. After calibration, few residual differences remained between groups. The primary outcome was not different in-hospital (3.0% vs 4.8%, p = 0.403) but less in NonIMP at 90 days (7.5% vs 13.8%, p = 0.033). Periprocedural vascular complications, bleeding, and transfusion rate did not differ between groups; however, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs 5.4%, p = 0.023). In conclusion, under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella-supported HR-PCI cohort showed similar MACE in-hospital but fewer MACE at 90 days, whereas there was no signal for periprocedural harm with Impella use. These results do not support routine usage of Impella for patients with HR-PCI.

Outcomes of a modified, low-cost, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for elective, periprocedural support of high-risk percutaneous cardiac interventions: An experience from a latinamerican center

INTRODUCTION

High-risk procedures in interventional cardiology include a wide spectrum of clinical and anatomical scenarios related to a higher periprocedural morbidity and mortality. The prophylactic use of short-term mechanical circulatory support (ST-MCS) may improve both the safety and efficacy of the intervention by leading to more stable procedural hemodynamics. However, the significant costs may limit its use in resource constrained settings. To overcome this limitation, we ideated a modified, low-cost, veno-arterial extracorporeal membrane oxygenator (V-A ECMO) setup.

METHODS

We conducted an observational prospective study including all patients undergoing a high-risk interventional cardiology procedure at our institution under prophylactic ST-MCS using a modified, low-cost version of V-A ECMO, where some components of the standard V-A ECMO circuit were replaced by supplies used for cardiac surgical cardiopulmonary bypass, achieving a cost reduction of 72%. We assessed in-hospital and mid-term outcomes, including procedural success, post-procedure complications and mortality.

RESULTS

Between March 2016 and December 2021, ten patients underwent high-risk IC procedures with prophylactic use of V-A ECMO. Isolated percutaneous intervention (PCI) was performed in six patients, isolated transcatheter aortic valve replacement (TAVR) in two, and a combined procedure (PCI + TAVR) in two. Mean ejection fraction was 34% (range 20-64%). Mean STS PROM was 16.2% (range 9.5-35.8%) and mean EuroScore was 23.7% (range 1.5-60%). The planned intervention was successfully performed in all cases. There were no reports of V-A ECMO malfunction. In nine patients the VA-ECMO was withdrawn immediately after the procedure but one patient required extended - 24 h - support with no significant issues. One patient experienced a periprocedural myocardial infarction and another developed a femoral pseudoaneurysm. In-hospital and 30-day survival were 100%, and 1-year survival was 80%.

CONCLUSIONS

High-risk procedures in interventional cardiology can be successfully performed under prophylactic ST-MCS using a modified, low-cost V-A ECMO, suitable for limited-resource settings.

Standby extracorporeal membrane oxygenation: a better strategy for high-risk percutaneous coronary intervention

Background

The incidence of cardiac arrest (CA) during percutaneous coronary intervention (PCI) is relatively rare. However, when it does occur, the mortality rate is extremely high. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promising survival rates for in-hospital cardiac arrests (IHCA), with low-flow time being an independent prognostic factor for CA. However, there is no definitive answer on how to reduce low-flow time.

Methods

This retrospective study, conducted at a single center, included 39 patients who underwent ECPR during PCI between January 2016 and December 2022. The patients were divided into two cohorts based on whether standby extracorporeal membrane oxygenation (ECMO) was utilized during PCI: standby ECPR (SBE) (n = 13) and extemporaneous ECPR (EE) (n = 26). We compared the 30-day mortality rates between these two cohorts and investigated factors associated with survival.

Results

Compared to the EE cohort, the SBE cohort showed significantly lower low-flow time (P < 0.01), ECMO operation time (P < 0.01), and a lower incidence of acute kidney injury (AKI) (P = 0.017), as well as peak lactate (P < 0.01). Stand-by ECMO was associated with improved 30-day survival (p = 0.036), while prolonged low-flow time (p = 0.004) and a higher SYNTAX II score (p = 0.062) predicted death at 30 days.

Conclusions

Standby ECMO can provide significant benefits for patients who undergo ECPR for CA during PCI. It is a viable option for high-risk PCI cases and may enhance the overall prognosis. The low-flow time remains a critical determinant of survival.

Predictors of left ventricular ejection fraction in high-risk percutaneous coronary interventions

Revascularization completeness after percutaneous coronary intervention (PCI) is associated with improved long-term outcomes. Mechanical circulatory support [intra-aortic balloon pump (IABP) or Impella] is used during high-risk PCI (HR-PCI) to enhance peri-procedural safety and achieve more complete revascularization. The relationship between revascularization completeness [post-PCI residual SYNTAX Score (rSS)] and left ventricular ejection fraction (LVEF) in HR-PCI has not been established. We investigated LVEF predictors at 90 days post-PCI with Impella or IABP support. Individual patient data (IPD) were analyzed from PROTECT II (NCT00562016) in the base case. IPD from PROTECT II and RESTORE-EF (NCT04648306) were naïvely pooled in the sensitivity analysis. Using complete cases only, linear regression was used to explore the predictors of LVEF at 90 days post-PCI. Models were refined using stepwise selection based on Akaike Information Criterion and included: treatment group (Impella, IABP), baseline characteristics [age, gender, race, New York Heart Association Functional Classification, LVEF, SYNTAX Score (SS)], and rSS. Impella treatment and higher baseline LVEF were significant predictors of LVEF improvement at 90 days post-PCI (p ≤ 0.05), and a lower rSS contributed to the model (p = 0.082). In the sensitivity analysis, Impella treatment, higher baseline LVEF, and lower rSS were significant predictors of LVEF improvement at 90 days (p ≤ 0.05), and SS pre-PCI contributed to the model (p = 0.070). Higher baseline LVEF, higher SS pre-PCI, lower rSS (i.e. completeness of revascularization), and Impella treatment were predictors of post-PCI LVEF improvement. The findings suggest potential mechanisms of Impella include improving the extent and quality of revascularization, and intraprocedural ventricular unloading.

Protected high risk percutaneous coronary intervention-Impella 5.0 as a single-access technique: a case report

Background

Patients requiring coronary intervention after acute myocardial infarction, with decompensated heart failure and multiple co-morbidities, present a challenging clinical scenario. Addressing such high-risk cases has been a marked increase in the simultaneous support using microaxial flow pump devices, providing a crucial haemodynamic support during procedures.

Case summary

We report the case of a 58-year-old man, with a non-ST-segment elevation myocardial infarction in the context of a peripheral vascular surgery. Echocardiography revealed severely reduced left ventricular function and cardiac magnetic resonance imaging demonstrated transmural scars in all but left anterior descending artery area. The patient was of extreme high surgical risk due to the multiple co-morbidities, acute decompensation heart failure, and peripheral artery disease, and, therefore, the heart team preferred protected percutaneous coronary intervention (PCI) over coronary artery bypass graft for revascularization. The peripheral artery disease included severely calcified ascending aorta, occlusions of both femoral arteries, the left subclavian artery, and the right radial artery. Taken together, the heart team agreed on a hybrid approach with surgical implantation of Impella 5.0 via the left subclavian artery, by a single-access technique. Following the intervention procedure, haemostasis of the vascular prosthesis was achieved by an angio-seal technique without complications. The patient recovered satisfactorily, with improved left ventricular function, and discharged 10 days post-procedure.

Discussion

The single-access high-risk PCI technique offers a standardized approach for microaxial flow pump devices such as Impella 5.0 and PCI. The subclavian artery as a single-access route for high-risk PCI has demonstrated safety and efficacy.

Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide, and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, has increased operators' confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications and the importance of adequate training and education.

Prophylactic ECMO Support during Elective Coronary Percutaneous Interventions in High-Risk Patients: A Single-Center Experience

Introduction

Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions.

Methods

This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success.

Results

Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis.

Conclusions

Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery.

Outcome of Impella 2.5 use in patients undergoing Percutaneous Coronary Intervention in Henan, China: a case series

BACKGROUND

Acute myocardial infarction (AMI) complicated by cardiogenic shock (AMI-CS) or heart failure is associated with an unacceptably high in-hospital mortality of 33%-55% and a lost chance to accept PCI (Percutaneous Coronary Intervention).

AIM

The aim of the study was to find out whether percutaneous hemodynamic support device Impella 2.5 improves prognosis of high-risk PCI patients or not.

METHODS

This study was a case series involving six patients who underwent a Left Ventricular Assist Device (LVAD, Impella 2.5, Abiomed, Danvers, MA) implantation after suffering from AMI with a very low ejection fraction and acute heart failure. The clinical experience and outcomes of the patients are hereby discussed.

RESULTS

All PCI procedures were safely completed under LVAD support. The hemodynamic parameters of all patients improved clinically over the next 30 days and following 12 months after Impella insertion except in two patients, of which one patient (Case number 6) died 4 days post-Impella protected PCI procedure due to acute left ventricle heart failure with cardiogenic shock and pulmonary oedema; and another one died at 12 months after Impella protected PCI procedure (Case number 4) due to decompensated heart failure and infected pneumonia.

CONCLUSION

Percutaneous hemodynamic support is favorable and feasible during high risk Percutaneous Coronary Intervention (PCI). A bigger study is needed to substantiate the claims of the current study.

Prophylactic Impella CP versus VA-ECMO in Patients Undergoing Complex High-Risk Indicated PCI

OBJECTIVES

To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

BACKGROUND

To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand.

METHODS

In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated.

RESULTS

A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference (p = 0.48). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09).

CONCLUSIONS

In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.

Optimized patient selection in high-risk protected percutaneous coronary intervention

Percutaneous mechanical circulatory support (pMCS) is increasingly used in patients with poor left-ventricular (LV) function undergoing elective high-risk percutaneous coronary interventions (HR-PCIs). These patients are often in critical condition and not suitable candidates for coronary artery bypass graft surgery. For the definition of HR-PCI, there is a growing consensus that multiple factors must be considered to define the complexity of PCI. These include haemodynamic status, left-ventricular ejection fraction, clinical characteristics, and concomitant diseases, as well as the complexity of the coronary anatomy/lesions. Although haemodynamic support by percutaneous LV assist devices is commonly adopted in HR-PCI (protected PCI), there are no clear guideline recommendations for indication due to limited published data. Therefore, decisions to use a nonsurgical, minimally invasive procedure in HR-PCI patients should be based on a risk-benefit assessment by a multidisciplinary team. Here, the current evidence and indications for protected PCI will be discussed.

Handling high-risk patients in the catheterization laboratory

Protected percutaneous coronary intervention is considered a life-saving procedure for high-risk patients. Therefore it is important that the interventional cardiology team is prepared, the procedure is planned, and potential complications, as well as bail out strategies are considered. Throughout the procedure, it is critical to monitor the patient to identify any early signs of deterioration or changes in patient well-being to avoid any potential complications.

Optimal bail-out and complication management strategies in protected high-risk percutaneous coronary intervention with the Impella

Despite the routine use of percutaneous mechanical circulatory support (pMCS) with the Impella heart pump, vascular and bleeding complications may occur during removal with or without pre-closure. To safely close the large-bore access (LBA), post-hoc selection of the appropriate treatment of vascular complications is critical to patient recovery and survival. Femoral artery access is typically utilized for LBA, and percutaneous axillary artery access is a common alternative, especially in the instance of severe peripheral artery disease. Optimization of patient outcomes and efficiency of pMCS can be achieved with adequate arterial access using state-of-the-art techniques. Impella removal techniques with or without pre-closure will be addressed as well as the management of large-bore femoral access complications. In addition, treatment strategies to manage patient deterioration during a protected high-risk percutaneous coronary intervention will be provided.

Patient Selection for Protected Percutaneous Coronary Intervention: Who Benefits the Most?

The evolution of percutaneous coronary intervention (PCI) enables a complete revascularization of complex coronary lesions. However, simultaneously, patients are presenting nowadays with higher rates of comorbidities, which may lead to a lower physiologic tolerance for complex PCI. To avoid hemodynamic instability during PCI and achieve safe complete revascularization, protected PCI using mechanical circulatory support devices has been developed. However, which patients would benefit from the protected PCI is still in debate. Hence, this review provides practical approaches for the selection of patients by outlining current clinical data assessing utility of protected PCI in high-risk patients.

Comparison of a pulsatile and a continuous flow left ventricular assist device in high-risk PCI

BACKGROUND

Mechanical circulatory support devices are able to generate additional cardiac output or maintain sufficient circulation during high-risk PCI. We prospectively compared the hemodynamic and clinical performance of the new iVAC2L® device with the Impella 2.5® device during high-risk PCI.

MATERIALS AND METHODS

In 40 patients [10 female, age 75 ± 8 years, left ventricular ejection fraction (LVEF) 44 ± 11%] high-risk PCIs were performed under iVAC (n = 20) or Impella (n = 20) support. Hemodynamic parameters were collected before and after device placement as well as immediately after PCI. Blood parameters of hemolysis were analyzed before and after support.

RESULTS

Correct device placement was achieved in 17 patients (85%) under iVAC use and in 19 patients (95%) under Impella use. PCI success was 98%. Under iVAC2L® support, systolic, diastolic and mean aortic blood pressure increased significantly with increasing support time. In contrast, aortic pressure increased directly under Impella support, but the increase was comparable between both devices. Impella support generated a significantly higher additional blood flow, as compared to iVAC support (2.07 ± 0.09 l/min vs. 1.25 ± 0.05 l/min, p < 0.001). Five patients (iVAC n = 3) suffered from critical events during high-risk PCI, but both devices were able to maintain stable hemodynamic conditions. After PCI, one severe bleeding occurred in each group. After Impella support, haptoglobin was significantly decreased, indicating potential hemolysis.

CONCLUSIONS

High-risk PCIs under support by both devices are feasible and safe and ensure stable hemodynamic conditions also if complications occur. Aortic pressure increases significantly with both devices, but later under iVAC use. Potential hemolysis occurs more frequent under Impella support.

Veno-Arterial Extracorporeal Membrane Oxygenation in Elective High-Risk Percutaneous Coronary Interventions

Background

The safety and feasibility of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as mechanical circulatory support in high-risk percutaneous coronary intervention (HR-PCI) remain unclear.

Methods

This retrospective study included patients with complex and high-risk coronary artery disease who underwent elective PCI with VA-ECMO support pre-operatively during March 2019–December 2020. Rates of VA-ECMO-related complications, complications during PCI, death, myocardial infarction, and stroke during hospitalisation and 1-year post-operatively were analysed.

Results

Overall, 36 patients (average age: 63.6 ± 8.9 years) underwent PCI. The average duration of VA-ECMO support was 12.5 (range, 3.0–26.3) h. Intra-aortic balloon pump counterpulsation was used in 44.4% of patients. The SYNTAX score was 34.6 ± 8.4 pre-operatively and 10.8 ± 8.8 post-operatively (P < 0.001). Intraoperative complications included pericardial tamponade (N = 2, 5.6%), acute left-sided heart failure (N = 1, 2.8%), malignant arrhythmia requiring electrocardioversion (N = 2, 5.6%), and no deaths. Blood haemoglobin levels before PCI and 24 h after VA-ECMO withdrawal were 145.4 ± 20.2 g/L and 105.7 ± 21.7 g/L, respectively (P < 0.001). Outcomes during hospitalisation included death (N = 1, 2.8%), stroke (N = 1, 2.8%), lower limb ischaemia (N = 2, 5.6%), lower limb deep venous thrombosis (N = 1, 2.8%), cannulation site haematoma (N = 2, 5.6%), acute renal injury (N = 2, 5.6%), bacteraemia (N = 2, 5.6%), bleeding requiring blood transfusion (N = 5, 13.9%), and no recurrent myocardial infarctions. Within 1 year post-operatively, two patients (5.6%) were hospitalised for heart failure.

Conclusions

Veno-arterial extracorporeal membrane oxygenation mechanical circulation support during HR-PCI is a safe and feasible strategy for achieving revascularisation in complex and high-risk coronary artery lesions. VA-ECMO-related complications require special attention.

Comparison of Contemporary Drug-Eluting Stents in Patients Undergoing Complex High-Risk Indicated Procedures

BACKGROUND

Limited data are available on the relative performances of diverse contemporary drug-eluting stents (DES) in patients undergoing complex high-risk indicated procedures (CHIP).

OBJECTIVES

The purpose of this study was to evaluate the comparative effectiveness of contemporary second-generation DES for CHIP patients in "real-world" settings.

METHODS

Of 28,843 patients enrolled in the IRIS-DES registry, a total of 6,645 patients with CHIP characteristics who received 5 different types of contemporary DES were finally included: 3,752 with cobalt-chromium everolimus-eluting stents (CoCr-EES), 1,258 with Resolute zotarolimus-eluting stents (Re-ZES), 864 with platinum-chromium EES (PtCr-EES), 437 with ultrathin strut biodegradable-polymer sirolimus-eluting stents (UT-SES), and 334 with bioresorbable polymer SES (BP-SES). The primary outcome was target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization) at 12 months.

RESULTS

At 12 months, the rate of target-vessel failure was highest in the CoCr-EES (7.1%) group; intermediate in the Re-ZES (5.0%), PtCr-EES (4.6%), and BP-SES (4.2%) groups; and lowest in the UT-SES (3.8%) group (overall long-rank P = 0.001). In multiple-treatment propensity-score analysis, the adjusted hazard ratios (HRs) for target-vessel failure were significantly lower in the Re-ZES (HR: 0.71; 95% confidence interval [CI]: 0.52-0.97), the UT-SES (HR: 0.52; 95% CI: 0.29-0.95), and BP-SES (HR: 0.33; 95% CI: 0.16-0.70) groups than in the CoCr-EES group (referent).

CONCLUSIONS

In this contemporary PCI registry, we observed the differential risks of target-vessel failure according to various types of contemporary DES in patients with CHIP characteristics. However, owing to inherent selection bias, the results should be considered hypothesis-generating, highlighting the need for further randomized trials. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133).

Rotablation in Patients with Advanced Renal Insufficiency through End-Stage Renal Disease: Short- and Intermediate-Term Results

Objective. Patients with advanced renal insufficiency are at high risk of coronary artery disease (CAD) and complex lesions. Treating complex calcified lesion with rotational atherectomy (RA) in these patients might be associated with higher risks and poorer outcomes. This study was set to evaluate features and outcomes of RA in these patients. Method. Consecutive patients who received coronary RA from April 2010 to April 2018 were queried from the Cath Lab database. The procedural details, angiography, and clinical information were reviewed in detail. Results. A total of 411 patients were enrolled and divided into Group A (baseline serum creatinine <5 mg/dl, n = 338) and Group B (baseline serum creatinine ≥ 5 mg/dl through ESRD, n = 73). Most patients had high-risk features (65.7% of acute coronary syndrome (ACS), 14.1% of ischemic cardiomyopathy, and 5.1% of cardiogenic shock). Group B patients were significantly younger (66.8 ± 11.4 vs. 75.2 ± 10.7 years, $p<0.001$ ) and had more RCA and LCX but less LAD treated with RA. No difference was found in lesion location, vessel tortuosity, bifurcation lesions, chronic total occlusion, total lesion length, or total lesion numbers between the two groups. Less patients in Group B obtained completion of RA (95.9% vs 99.1%, $p=0.037$ ). There was no difference in the incidence of procedural complication or acute contrast-induced nephropathy. Group B patients had more deaths and MACE while in the hospital. The MACE and CV MACE were also higher in Group B patients at 180 days and one year, mostly due to TLR and TVR. Multivariate regression analysis showed that ACS, age, peripheral artery disease (PAD), advanced renal insufficiency, ischemic cardiomyopathy/shock, and high residual SYNTAX score were independent risk factors for in-hospital MACE, whereas ACS, advanced renal insufficiency, ischemic cardiomyopathy/shock, triple-vessel disease, and PAD independently predicted MACE at 6 months. Conclusions. Rotablation is feasible, safe, and could be carried out with very high success rate in very-high-risk patients with advanced renal dysfunction through ESRD without an increase in procedural complication.

A Review of the Impella Devices

The use of mechanical circulatory support (MCS) to provide acute haemodynamic support for cardiogenic shock or to support high-risk percutaneous coronary intervention (HRPCI) has grown over the past decade. There is currently no consensus on best practice regarding its use in these two distinct indications. Impella heart pumps (Abiomed) are intravascular microaxial blood pumps that provide temporary MCS during HRPCI or in the treatment of cardiogenic shock. The authors outline technical specifications of the individual Impella heart pumps and their accompanying technology, the Automated Impella Controller and SmartAssist, their indications for use and patient selection, implantation techniques, device weaning and escalation, closure strategies, anticoagulation regimens, complications, future directions and upcoming trials.

Future Devices for Percutaneous Mechanical Circulatory Support

Percutaneous mechanical circulatory support options include intra-aortic balloon pump, transvalvular axial flow pumps, left atrial to femoral artery pumping, and oxygenated right atrium to femoral artery circuits. Percutaneous mechanical circulatory support devices providing greater support have not proven superiority over the intra-aortic balloon pump. Novel counterpulsation devices target durability and ambulatory capability and direct unloading of left ventricle (LV) and right ventricle. Device innovations in transvalvular axial pumping include miniaturization of partial-support devices and development of larger self-expanding devices for near-complete LV support. Aortic entrainment pumping is a novel mode of blood displacement with potential benefits beyond reduced LV afterload.

Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices

There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.

Feasibility and Safety of High-Risk Percutaneous Coronary Intervention Without Mechanical Circulatory Support

[Figure: see text].

Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices

There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.

Left Ventricle Architecture and Valvular Integrity Following Microaxial Mechanical Support: A Two-Year Follow-Up Study

Although the use of microaxilar mechanical circulatory support systems may improve the outcome of patients with cardiogenic shock (CS), little is known about its effect on the long-term structural integrity of left ventricular (LV) valves as well as on the development of LV-architecture. Therefore, we aimed to study the integrity of the LV valves and architecture and function after Impella support. Thus, 84 consecutive patients were monitored over two years having received Impella^TM CP (n = 24) or 2.5 (n = 60) for refractory CS (n = 62) or for high-risk percutaneous coronary interventions (n = 22) followed by optimal medical treatment. Beside a significant increase in LV ejection fraction after two years (p ≤ 0.03 vs. pre-implantation), we observed a statistically significant decrease in LV dilation (p < 0.001) and severity of mitral valve regurgitation (p = 0.007) in the two-year follow-up period, suggesting an improved LV architecture. Neither the duration of support, nor the size of the Impella device or the indication for its use revealed any devastating impact on aortic or mitral valve integrity. These findings indicate that Impella device is a safe means of support of LV-function without detrimental long-term effects on the structural integrity of LV valves regardless of the size of the device or the indication of support.

Intra-Aortic Balloon Pump and Ischemic Cardiogenic Shock May Still Be a Valuable Association

The IABP gives rise to greater myocardial perfusion by increasing the coronary pressure gradient from the aorta to the coronary circulation at a time when the aortic valve is closed [...].

Mechanical circulatory support with Impella in percutaneous coronary intervention: current status

In patients with, or at risk of, hemodynamic instability during percutaneous coronary intervention, maintaining perfusion of vital organs is crucial. The intra-aortic balloon pump and Impella are the two most commonly used percutaneous mechanical circulatory support devices. Intra-aortic balloon pump has been in widespread use for over three decades. Mechanical circulatory support with Impella is being used increasingly often in patients with acute myocardial infarction complicated by cardiogenic shock, and in those undergoing high-risk percutaneous coronary intervention. Besides improving cardiac output and coronary perfusion, Impella has potential myocardial protective effects. Three key measures that determine the clinical utility of a device are clinical outcome, device-related complications, and cost impact. In this review, the current data on use of Impella in patients with acute myocardial infarction complicated by cardiogenic shock, in left ventricular unloading in acute myocardial infarction, and in those undergoing high-risk percutaneous coronary intervention is analyzed.

The role of mechanical support devices during percutaneous coronary intervention

The practice of interventional cardiology has changed dramatically over the last four decades since Andreas Gruentzig carried out the first balloon angioplasty. The obvious technological improvements in stent design and interventional techniques have facilitated the routine treatment of a higher risk cohort of patients, including those with complex coronary artery disease and poor left ventricular function, and more often in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (AMI). The use of mechanical cardiac support (MCS) in these settings has been the subject of intense interest, particularly over the past decade . A number of commercially available devices now add to the interventional cardiologist's armamentarium when faced with the critically unwell or high-risk patient in the cardiac catheter laboratory. The theoretical advantage of such devices in these settings is clear- an increase in cardiac output and hence mean arterial pressure, with variable effects on coronary blood flow. In doing so, they have the potential to prevent the downward cascade of ischaemia and hypoperfusion, but there is a paucity of evidence to support their routine use in any patient subset, even those presenting with cardiogenic shock. This review will discuss the use and haemodynamic effect of MCS devices during percutaneous coronary intervention (PCI), and also examine the clinical evidence for their use in patients with cardiogenic shock, and those undergoing 'high risk' PCI.

A Review of Bleeding Risk with Impella-supported High-risk Percutaneous Coronary Intervention

Complex, high-risk percutaneous coronary intervention (HR-PCI) is increasingly being performed, often with mechanical circulatory support (MCS), though to date, there are limited randomised data on the efficacy of MCS for HR-PCI. The majority of MCS is provided by intra-aortic balloon pumps, but increasingly Impella® (Abiomed, Danvers, MA, USA) heart pumps are being used. While the Impella pumps provide greater increases in cardiac output, these devices require large bore access, which has been associated with an increased risk of bleeding and vascular complications. Decisions regarding the use of Impella are often based on risk-benefit considerations, with Impella-related bleeding risk being a major factor that can impact decisions for planned use. While bleeding risk related to large bore access is a concern, published data on the risk have been quite variable. Thus, the goal of this article is to provide a comprehensive review of reports describing bleeding and vascular complications for Impella-supported HR-PCI.

The Physiologic Basis and Clinical Outcomes of Combined Impella and Veno-Arterial Extracorporeal Membrane Oxygenation Support in Cardiogenic Shock

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides effective hemodynamic support in cardiogenic shock, but in some cases may be complicated by left ventricular (LV) distension and pulmonary edema. The Impella, a catheter-mounted microaxial pump has been used to unload the LV. Recent studies have compared the clinical outcomes of VA-ECMO to the combination of Impella and VA-ECMO. The purpose of this review is threefold: firstly, to discuss the physiological effects of Impella support in addition to VA-ECMO, secondly to review published studies on the outcome of this combined support, and thirdly to provide a practical overview of the approach to combining Impella and VA-ECMO.

Patient and Device Selection for Hemodynamic Support in High-Risk Percutaneous Coronary Intervention

Coronary artery disease continues to advance resulting in the development of high-risk percutaneous interventions. This includes treatment of patients with multivessel disease, unprotected left main, acute myocardial infarction complicated by cardiogenic shock, and depressed left ventricular ejection fraction. As a result, mechanical circulatory support devices have evolved but require an understanding of patient hemodynamics, device mechanics, and access management. Trial data regarding device selection are limited by inclusion of cardiogenic shock patients, and observational studies are conflicted by selection bias, site familiarity with devices, and complication management; therefore, clinical judgment is required to treat high-risk patients appropriately.

Impact of Diabetes Mellitus on Outcomes after High-Risk Interventional Coronary Procedures

An increasing number of patients with coronary artery disease are at high operative risk due to advanced age, severe comorbidities, complex coronary anatomy, and reduced ejection fraction. Consequently, these high-risk patients are often offered percutaneous coronary intervention (PCI) as an alternative to coronary artery bypass grafting (CABG). We aimed to investigate the outcome of patients with diabetes mellitus (DM) undergoing high-risk PCI. We analyzed consecutive patients undergoing high-risk PCI (period 01/2016-08/2018). In-hospital major adverse cardiac and cerebrovascular events (MACCEs), defined as in-hospital stroke, myocardial infarction and death, and the one-year incidence of death from any cause were assessed in patients with and without DM. There were 276 patients (age 70 years, 74% male) who underwent high-risk PCI. Eighty-six patients (31%) presented with DM (insulin-dependent DM: n = 24; non-insulin-dependent DM: n = 62). In-hospital MACCEs occurred in 9 patients (3%) with a non-significant higher rate in patients with DM (n = 5/86, 6% vs. n = 4/190 2%; p = 0.24). In patients without DM, the survival rate was insignificantly higher than in patients with DM (93.6% vs. 87.1%; p = 0.07). One-year survival was not significantly different in DM patients with more complex coronary artery disease (SYNTAX I-score ≤ 22: 89.3% vs. > 22: 84.5%; p = 0.51). In selected high-risk patients undergoing high-risk PCI, DM was not associated with an increased incidence of in-hospital MACCEs or a decreased one-year survival rate.

Patient Selection for Protected Percutaneous Coronary Intervention: Who Benefits the Most?

The evolution of percutaneous coronary intervention (PCI) enables a complete revascularization of complex coronary lesions. However, simultaneously, patients are presenting nowadays with higher rates of comorbidities, which may lead to a lower physiologic tolerance for complex PCI. To avoid hemodynamic instability during PCI and achieve safe complete revascularization, protected PCI using mechanical circulatory support devices has been developed. However, which patients would benefit from the protected PCI is still in debate. Hence, this review provides practical approaches for the selection of patients by outlining current clinical data assessing utility of protected PCI in high-risk patients.

Clinical Characteristics and Outcomes From Percutaneous Coronary Intervention of Last Remaining Coronary Artery

Background:

Patients with complex high-risk coronary anatomy, such as those with a last remaining patent vessel (LRPV), are increasingly revascularized with percutaneous coronary intervention (PCI) in contemporary practice. There are limited data on the outcomes of these high-risk procedures.

Methods:

We analyzed a large longitudinal PCI cohort (2007–2014, n=501 841) from the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing patients into 2 groups; LRPV group (n=2432) and all other PCI groups (n=506 691).

Results:

Patients in the LRPV PCI group were older, had more comorbidities, and higher prevalence of moderate-severe left ventricular systolic dysfunction. Mortality was higher in the LRPV PCI group during hospital admission (12 % versus 1.5 %, P <0.001), at 30 days (15% versus 2%, P <0.001), and at one-year (24% versus 5%, P <0.001). In a propensity score matching analysis the adjusted risk of mortality during index admission (odds ratio, 2.05 [95% CI, 1.65–2.44], P <0.001), at 30 days (odds ratio, 2.13 [95% CI, 1.78–2.5], P <0.001), at 1 year (odds ratio, 1.81 [95% CI, 1.59–2.03], P <0.001), and in-hospital major adverse cardiovascular events (odds ratio, 1.8 [95% CI, 1.42–2.19], P <0.001) were higher in LRPV PCI group as compared to control group. In sensitivity analyses, similar clinical outcomes were observed irrespective of which major epicardial coronary artery was treated.

Conclusions:

In this contemporary cohort, patients who had PCI to their LRPV had a higher-risk profile and more adverse clinical outcomes, irrespective of the vessel treated.

Protected Percutaneous Coronary Intervention (PCI) of Cabrol Type Anastomosis of Saphenous Vein Graft (SVG) to the Left Main Coronary Artery (LMCA)

The use of percutaneous left ventricular assist devices (VAD) may minimize the risk of hemodynamic compromise during such high-risk percutaneous coronary intervention (PCI) and allow complete revascularization, thus improving outcomes. A good understanding of cardiac hemodynamics is essential in making informed decisions during such cases. A 61-year-old male with an extensive surgical cardiac history including a modified Cabrol type anastomosis with saphenous vein (SVG) conduits to two coronary arteries presented to our hospital with severe substernal chest discomfort and was noted to have diffuse ST depressions along with subtle ST elevations in lead aVR suggestive of diffuse sub-endocardial ischemia. Diagnostic coronary angiography revealed significant stenosis in the Cabrol type SVG grafts and we opted for a protected PCI using Impella (Abiomed, Danvers, MA) support. A significant drop in the blood pressure was noted and despite trouble-shooting, the Impella arterial line tracing remained minimally pulsatile.​ A comprehensive understanding of circulatory support physiology was ultimately crucial in making an informed decision for a successful PCI outcome.

A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation

BACKGROUND

Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest.

METHODS

Fifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed.

RESULTS

Indications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7.

CONCLUSIONS

A variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.

Impact of left-ventricular end-diastolic pressure as a predictor of periprocedural hemodynamic deterioration in patients undergoing Impella supported high-risk percutaneous coronary interventions

BACKGROUND

An increasing number of high-risk percutaneous coronary interventions (PCI) are performed with mechanical circulatory support (MCS) to minimize the risk of periprocedural hemodynamic compromise. Prior studies have demonstrated that an elevated left-ventricular end-diastolic pressure (LVEDP) is associated with worse outcome after acute myocardial infarction or cardiac surgery. Although LVEDP is frequently measured, little is known about the usefulness for predicting periprocedural hemodynamic deterioration in high-risk PCI. The objective of this study is to assess the impact of preprocedural measured LVEDP in non-shock patients undergoing high-risk PCI with MCS on periprocedural hemodynamic deterioration.

METHODS AND RESULTS

We reviewed the PCI protocol and the Automated Impella Controller in a consecutive series of 64 patients (mean age 73 years, 80% male), who underwent high-risk PCI with Impella MCS (period 01/2017-12/2018). LVEDP (17 ± 8 mm Hg) was measured in all cases before Impella insertion and start of PCI. Periprocedural hemodynamic deterioration was defined as: systolic blood pressure (SBP) drop (decrease ≥20 mm Hg or ≤90 mm Hg), or transient loss of arterial pressure pulsatility. Hemodynamic deterioration occurred in 33% (n = 21) of all patients but did not lead to a hemodynamic compromise due to the Impella support. Regression analysis of LVEDP for periprocedural hemodynamic deterioration or in-hospital major adverse cardiac and cerebrovascular events (MACCE) showed no significant results.

CONCLUSION

LVEDP was not associated with periprocedural hemodynamic deterioration or a higher rate of in-hospital MACCE. Our data propose that LVEDP may not be used as a risk stratification variable for MCS usage in non-shock patients undergoing high-risk PCI.

Safety and efficacy of a novel algorithm to guide decision-making in high-risk interventional coronary procedures

BACKGROUND

Patients with severe coronary artery disease (CAD), comorbidities, or impaired hemodynamics are at risk during percutaneous coronary interventions. The aim of the study was to investigate the safety and efficacy of a novel risk-stratification algorithm for high-risk coronary procedures.

METHODS AND RESULTS

We prospectively screened 1189 patients with CAD requiring revascularization (period 07/2017-06/2018). The algorithm was designed to select high-risk procedures. Patients with elevated risk (n = 150) were classified into 3 risk groups (high-risk intervention [HRI] I-III) and procedural management was adjusted according to HRI group. Overall, 55 patients were categorized as HRI I, 52 as HRI II, and 43 as HRI III. With increasing HRI-level, SYNTAX score increased (HRI I:15 ± 5% vs. HRI II:24 ± 8% vs. HRI III:34 ± 7%; p < 0.001), and ejection-fraction decreased (HRI I:48 ± 10% vs. HRI II:49 ± 10% vs. HRI III:40 ± 11%; p < 0.001). The primary endpoint (hemodynamic compromise requiring mechanical circulatory support [MCS] [HRI I/II], unsuccessful weaning from MCS in the catheterization laboratory[HRI III], or periprocedural death[HRI I-III]) occurred in no case. The secondary endpoint of hemodynamic deterioration occurred in 26% (n = 39) but did not result in hemodynamic instability due to the risk-adjusted procedural management. The composite endpoint of in-hospital major adverse cardiac and cerebrovascular events (death, new myocardial infarction, cerebrovascular accident) occurred in 4 patients (3%).

CONCLUSIONS

The novel algorithm is a safe team-based stratification method for the identification and management of patients undergoing high-risk coronary interventions.

Analysis: Intravascular Devices with a Higher Risk of Polymer Emboli: The Need for Particulate Generation Testing

Hydrophilic polymer coatings on intravascular devices lower friction between the device and vasculature, thereby reducing trauma during interventional procedures. Polymer coating embolism-the detachment and downstream embolism of polymer particles-has been reported as an iatrogenic complication of coated interventional devices affecting the vasculature and various organs. The Food and Drug Administration (FDA) acknowledges this complication and continues to work with stakeholders to close gaps in performance testing and standards related to polymer coating integrity. Recent innovations within interventional technologies have led to development of new hydrophilic-coated devices with expanded indications for use. The 2018 FDA draft guidance for intravascular guidewires expands the application of particulate generation testing to most devices and recommends labeling changes to increase industry awareness. This article highlights current procedural trends where the phenomenon of polymer coating embolism may be more prevalent. It describes the mechanisms of polymer separation, reported clinical sequelae, and risk factors for relevant indications. These procedural trends and associated risk factors articulate the need for particulate testing and support the FDA's draft guidance recommendations for performance testing of applied coatings. If standardized, particulate assessments may allow characterization and comparisons of coating integrity among devices from various manufacturers, and are an important foundation for setting particulate limits. As hydrophilic coatings enable endovascular treatment for a range of patient populations, setting particulate limits or finding alternative solutions without compromise to device function may be essential. Particulate testing is relevant to physicians, regulators, and manufacturers for the purposes of product development and quality improvement of interventional devices.