Left atrial venous arterial extracorporeal membrane oxygenation for biventricular failure in cardiogenic shock

Background

Cardiogenic shock complicated by biventricular (BIV) heart failure is associated with high mortality. Venous-arterial extra-corporeal membrane oxygenation is limited by the increase of left ventricular (LV) afterload. Complex configurations of paired circulatory support devices have been used with mixed results due to vascular access complications. One way to simply vascular access is to place a transseptal cannula under echocardiographic guidance with a long fenestrated segment enabling simultaneous left and right sided unloading known as left-atrial venous arterial (LAVA) ECMO.

Purpose

We aimed to review the safety and outcomes of LAVA ECMO utilized for shock at our institution.

Methods

Retrospective analysis of our Hospital Cath Lab Database yielded 6 patients undergoing LAVA-ECMO for shock from 7/2020–3/2021. Patient characteristics, procedural data and outcomes were analyzed. Variables are either expressed as proportions or medians (Interquartile range; IQR).

Results

Median age was 55.5 years (IQR, 51–61) and most patients were men (83.3%). Median baseline LV ejection fraction was 38% (IQR, 23–56%) and all had right ventricular dysfunction. 4/6 (66.7%) had severe valvular dysfunction including aortic regurgitation (2/6), mitral regurgitation (2/6) and mitral stenosis (1/6). One patient had a LV thrombus and hemodynamics necessitated LV unloading. Intracardiac echocardiography was used to guide the transseptal puncture in 5/6 (83%). Transesophageal echocardiography was used in one case. Procedural outcomes and hemodynamic variables are outlined in Tables 1 and 2 consecutively. One case of limb ischemia resulted from an embolus in the contralateral limb. LAVA-ECMO bridged 83% of patients to valve replacement, durable ventricular support or heart transplant (Table 1).

Conclusions

LAVA-ECMO provides BIV support with a single circuit and successfully bridged patients without direct complications. Given the safety, efficacy and simplified configuration of LAVA-ECMO, prospective studies are indicated.

Funding Acknowledgement

Type of funding sources: None.

Use of left ventricular support devices during transcatheter aortic valve replacement and balloon aortic valvuloplasty: a single center experience

Background

Transcatheter aortic valve replacement (TAVR) and balloon aortic valvuloplasty (BAV) are definitive and bridging therapies in patients with aortic stenosis. Data on utilization of mechanical circulatory support (MCS) in this population is scarce. This study sought to evaluate the clinical outcomes of the use of Impella (Abiomed, Danvers, MA) in patients undergoing TAVR or BAV at a tertiary-care center.

Methods

We reviewed all TAVRs and BAVs that required Impella from 2012 and 2020. Patient demographics, procedural outcomes, complications, and 30-day mortality were analyzed.

Results

A total of 1,965 TAVR and 715 BAV cases were performed in the study period. 30 TAVR and 94 BAV cases required an Impella. 65% of these cases were due to cardiogenic shock (CS) (100% of TAVR and 55% of BAV). 31% were performed in female patients. Transfemoral access was utilized in 98% of cases. Impella CP was used in 98% of cases, other types of MCS were used in 8.7% of cases. 32.2% of cases required MCS for more than 24 hours. In the TAVR population the indication for MCS was 46.6% profound hypotension post valve deployment requiring vasopressors, 16.6% cardiac arrest, 10% sustained ventricular arrhythmia, 10% cardiac tamponade [Office1] and 10% coronary occlusion. In the BAV group the indication was 44% high-risk PCI and 56% CS. The 30-day mortality in TAVR was 40% and 28% in BAV; from the BAV group in CS the mortality was 45%. VARC-2 vascular complications and bleeding complications were observed in 4.8% and 1.5%, respectively. 0.7% of the total cohort required conversion to open-heart surgery.

Conclusions

Impella support is required in a minority of TAVR or BAV cases. In those who require MCS with Impella for either BAV or TAVR, the total mortality remains high especially in those experiencing CS.

Funding Acknowledgement

Type of funding sources: None.

Demographic and Technical Risk Factors of 30-Day Stroke, Myocardial Infarction, and/or Death in Standard- and High-Risk Patients Who Underwent Carotid Angioplasty and Stenting

BACKGROUND

Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS.

MATERIALS AND METHODS

This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study.

RESULTS

A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively).

CONCLUSION

There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.