The Role of Percutaneous Haemodynamic Support in High-risk Percutaneous Coronary Intervention and Cardiogenic Shock

Effect of Atrioventricular Dyssynchrony on Impella Hemodynamics: Mechanism and Its Clinical Implications

The physiologic importance of atrial systole and atrioventricular (AV) synchrony in maintaining cardiac performance is well established. However, the role of AV synchrony in maintaining adequate Impella output has not been fully evaluated. Despite the common belief that AV dyssynchrony does not affect Impella output, given that Impella is a continuous flow device, recent reports indicate that AV dyssynchrony can lead to low Impella output in patients with cardiogenic shock complicated by complete heart block. Temporary transvenous pacing without establishing AV synchrony may fail to improve Impella hemodynamics; therefore, understanding the mechanism of low Impella output in AV dyssynchrony and promptly restoring AV synchrony may improve Impella output in such cases and lead to better outcomes.

Left Ventricular Rupture After Impella® Placement During High-Risk Percutaneous Coronary Intervention

Ventricular perforation is a rare complication during a high-risk percutaneous coronary intervention (PCI) when supported by Impella® (Abiomed). However, instrumentation of the left ventricle several days after transmural infarct potentially increases susceptibility for perforation. While a patient is on Impella support, physicians should review ventriculograms carefully to detect perforation and should consider the presence of a decompressed ventricle, the absence of normal systolic pressure and the movement of contrast from the ventricle into the aorta bypassing the left ventricular ejection. Immediate removal of the Impella if a perforation occurs must be avoided. Retrieving the device would risk a catastrophic bleed, while alternative repair techniques are available. Here, we describe a patient with a left ventricle perforation that occurred during a high-risk PCI supported by an Impella device. ANNOTATED SUMMARY: The repair of a left ventricle perforation during high-risk PCI in a patient who had an unrecognized left ventricular perforation is described. Physicians are encouraged to carefully review ventriculograms to identify the subtle changes that can indicate a perforation. Further, immediate removal of the temporary LVAD should be avoided to minimize the risk of catastrophic bleeds.