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Aslam MI, Gruslova AB, Almomani A, Nolen D, Elliott JJ, Jani VP, Kottam A, Porterfield J, Heighten C, Anderson AS, Valvano JW, Feldman MD. Modification of a Transvalvular Microaxial Flow Pump for Instantaneous Determination of Native Cardiac Output and Volume. J Card Fail 2023; 29:1369-1379. [PMID: 37105397 DOI: 10.1016/j.cardfail.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. OBJECTIVES This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. METHODS Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. RESULTS Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. CONCLUSIONS We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. CONDENSED ABSTRACT Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.
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Affiliation(s)
- M Imran Aslam
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Aleksandra B Gruslova
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ahmed Almomani
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Drew Nolen
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - James J Elliott
- Department of Laboratory Animal Resources, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Vivek P Jani
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anil Kottam
- BridgeSource Medical Corporation, Austin, Texas
| | | | | | - Allen S Anderson
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jonathan W Valvano
- Department of Electrical Engineering, University of Texas at Austin, Austin, Texas
| | - Marc D Feldman
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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Tersalvi G, Attinger-Toller A, Kalathil D, Winterton D, Cioffi GM, Madanchi M, Seiler T, Stadelmann M, Goffredo F, Fankhauser P, Moccetti F, Wolfrum M, Toggweiler S, Bloch A, Kobza R, Cuculi F, Bossard M. Trajectories of Cardiac Function Following Treatment With an Impella Device in Patients With Acute Anterior ST-Elevation Myocardial Infarction. CJC Open 2022; 5:77-85. [PMID: 36700188 PMCID: PMC9869354 DOI: 10.1016/j.cjco.2022.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Left ventricular (LV) unloading via the percutaneous micro-axial Impella pump is increasingly used in patients with anterior ST-segment elevation myocardial infarction (STEMI) and overt cardiogenic shock. In this context, the evolution of cardiac function and dimensions beyond hospital discharge remains uncertain. We aimed to characterize echocardiographic changes over time in patients with acute anterior STEMI treated with an Impella device. Methods From an ongoing prospective registry, consecutive patients with acute anterior STEMI managed with an Impella device were extracted. Transthoracic echocardiography was performed at index hospitalization and at first outpatient follow-up. Predictors of response, defined as a ≥ 10% absolute increase in left ventricular ejection fraction (LVEF) at follow-up, were sought. Results A total of 66 patients (89.4% male, aged 64.3 ± 11.6 years) with anterior STEMI were treated with an Impella device in the first 24 hours of hospitalization, from 2014 to 2022. In-hospital mortality was 24%. Major bleeding and vascular complications requiring surgery occurred in 24% and 11% of patients, respectively. At baseline, mean LVEF was 34% ±12%. At follow-up, survivors showed a significant increase in LVEF (P < 0.0001), whereas LV dimensions, diastolic parameters, and measures of right ventricular dimension and function remained stable. Overall, 28 patients had a ≥ 10% absolute increase in LVEF at follow-up. Baseline creatinine was the only significant predictor of response at univariate analysis. Conclusions Among patients with anterior STEMI requiring mechanical hemodynamic support with an Impella device, the majority of survivors showed a sustained increase in LV function, without evidence of adverse remodelling. This signal warrants further investigation in dedicated trials.
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Affiliation(s)
- Gregorio Tersalvi
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Dhanya Kalathil
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Dario Winterton
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mehdi Madanchi
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Thomas Seiler
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Marc Stadelmann
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Francesca Goffredo
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Patrick Fankhauser
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Federico Moccetti
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mathias Wolfrum
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Stefan Toggweiler
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Bloch
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Kobza
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Bossard
- Cardiology Division, Heart Centre, Luzerner Kantonsspital, Lucerne, Switzerland,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland,Corresponding author: Dr Matthias Bossard, Cardiology Division – Heart Centre Lucerne, Luzerner Kantonsspital, 6000 Luzern 16, Lucerne, Switzerland. Tel.: +41 41 205 14 77.
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3
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Mierke J, Nowack T, Loehn T, Kluge F, Poege F, Speiser U, Woitek F, Mangner N, Ibrahim K, Linke A, Pfluecke C. Predictive value of the APACHE II score in cardiogenic shock patients treated with a percutaneous left ventricular assist device. IJC HEART & VASCULATURE 2022; 40:101013. [PMID: 35372664 PMCID: PMC8971639 DOI: 10.1016/j.ijcha.2022.101013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/11/2022] [Accepted: 03/20/2022] [Indexed: 12/11/2022]
Abstract
Background The APACHE II score assesses patient prognosis in intensive care units. Different disease entities are predictable by using a specific factor called Diagnostic Category Weight (DCW). We aimed to validate the prognostic value of the APACHE II score in patients treated with a percutaneous left ventricular assist device because of refractory cardiogenic shock (CS). Methods From the Dresden Impella Registry, we analyzed 180 patients receiving an Impella CP®. The main outcome was the observed intrahospital mortality (S ^ ( t h o s p ) ), which was compared to the predicted mortality estimated by the APACHE II score. Results The APACHE II score, which was 33.5 ± 0.6, significantly overestimated intrahospital mortality (S ^ ( t h o s p ) 54.4 ± 3.7% vs. APACHE II 74.6 ± 1.6%; p < 0.001). Nevertheless, the APACHE II score showed an acceptable accuracy to predict intrahospital mortality (ROC AUC 0.70; 95% CI 0.62-0.78). Thus, we adapted the formula for calculation of predicted mortality by adjusting DCW. The total registry cohort was randomly divided into derivation group for calculation of adjusted DCW and validation group for testing. Intrahospital mortality was much more precisely predicted using the adjusted DCW compared to the conventional DCW (difference of predicted and observed mortality: -4.7 ± 2.4% vs. -23.2 ± 2.3%; p < 0.001). The new calculated DCW was -1.183 for the total cohort. Conclusion The APACHE II score has an acceptable accuracy for the prediction of intrahospital mortality but overestimates its total amount in CS patients. Adjustment of the DCW can lead to a much more precise prediction of prognosis.
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Affiliation(s)
- Johannes Mierke
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Thomas Nowack
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Tobias Loehn
- Kreiskrankenhaus Freiberg, Klinik für Innere Medizin II, Freiberg, Germany
| | - Franziska Kluge
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Frederike Poege
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Uwe Speiser
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Felix Woitek
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Norman Mangner
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Karim Ibrahim
- Klinikum Chemnitz, Klinik für Innere Medizin I, Chemnitz, Germany
| | - Axel Linke
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Christian Pfluecke
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
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Attinger-Toller A, Bossard M, Cioffi GM, Tersalvi G, Madanchi M, Bloch A, Kobza R, Cuculi F. Ventricular Unloading Using the Impella TM Device in Cardiogenic Shock. Front Cardiovasc Med 2022; 9:856870. [PMID: 35402561 PMCID: PMC8984099 DOI: 10.3389/fcvm.2022.856870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.
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Affiliation(s)
- Adrian Attinger-Toller
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland,*Correspondence: Adrian Attinger-Toller
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Gregorio Tersalvi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
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Gottula AL, Shaw CR, Milligan J, Chuko J, Lauria M, Swiencki A, Bonomo J, Ahmad S, Hinckley WR, Gorder KL. Impella in Transport: Physiology, Mechanics, Complications, and Transport Considerations. Air Med J 2022; 41:114-127. [PMID: 35248330 DOI: 10.1016/j.amj.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/10/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency. Critical care transport medicine crews are required to transport patient support by the Impella device with increasing frequency. It is important that critical care transport medicine crews are familiar with the Impella device and are able to troubleshoot complications that may arise in the transport environment. This article reviews many aspects of the Impella device critical to the transport of this complex patient population.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Anesthesiology, University of Michigan, Ann Arbor, MI.
| | - Christopher R Shaw
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Justine Milligan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Jonathan Chuko
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Michael Lauria
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Amy Swiencki
- Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
| | - Saad Ahmad
- Department of Internal Medicine, Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Air Care & Mobile Care, University of Cincinnati Health, Cincinnati, OH
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Meani P, Lorusso R, Pappalardo F. ECPella: Concept, Physiology and Clinical Applications. J Cardiothorac Vasc Anesth 2021; 36:557-566. [PMID: 33642170 DOI: 10.1053/j.jvca.2021.01.056] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023]
Abstract
Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.
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Affiliation(s)
- P Meani
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy; ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - R Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - F Pappalardo
- Department of Anaesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
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Percutaneous Left Ventricular Assist Device Leads to Heart Rhythm Stabilisation in Cardiogenic Shock: Results from the Dresden Impella Registry. Heart Lung Circ 2020; 30:577-584. [PMID: 33039280 DOI: 10.1016/j.hlc.2020.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/06/2020] [Accepted: 08/15/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Severe heart rhythm disturbances (SHRDs) occur regularly in cardiogenic shock (CS). Percutaneous left ventricular assist devices (pLVADs) can actively unload the left ventricle (LV), decreasing left ventricular end-diastolic pressure and wall tension, which are suspected parameters for the induction and maintenance of arrhythmias. The aim of this study was to describe effects of LV unloading on SHRD. METHOD In the Dresden Impella Registry, 97 patients received an Impella CP in refractory CS. Of them, 19 had SHRDs, which were not stopped by common therapeutic strategies such as electrical defibrillation or antiarrhythmic drugs. They were only stopped after implantation of a micro-axial heart pump. This phenomenon was referred to as heart rhythm stabilisation (HRS). Clinical outcome and laboratory parameters were assessed and risk factors for the occurrence of HRS were identified. RESULTS All 19 patients with refractory SHRD terminated immediately into a stable heart rhythm after insertion of the micro-axial heart pump. In 37% no additional defibrillation was needed. Of the patients with HRS, CS was mostly caused by myocardial infarction (68%). Resuscitation before pLVAD was performed in 89% for more than 30 minutes. Patients with HRS were resuscitated more frequently and for a longer duration than patients without HRS. After HRS, the serum lactate and norepinephrine dosage decreased in the first 12 hours, whereas left ventricular ejection fraction increased by 95%. CONCLUSIONS Left ventricular unloading in patients with CS seems to be an option for treating patients with sustained life-threatening tachycardia, who are refractory to common treatment.
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Koutroumpakis E. Impella 2.5 Insertion: Which Artery to Access When Femoral Is not an Option? JACC Case Rep 2020; 2:1888-1890. [PMID: 34317074 PMCID: PMC8299128 DOI: 10.1016/j.jaccas.2020.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Efstratios Koutroumpakis
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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9
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Six months follow-up of protected high-risk percutaneous coronary intervention with the microaxial Impella pump: results from the German Impella registry. Coron Artery Dis 2020; 31:237-242. [DOI: 10.1097/mca.0000000000000824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Kado Y, Smith WA, Miyamoto T, Adams J, Polakowski AR, Dessoffy R, Horvath DJ, Fukamachi K, Karimov JH. Use of a Virtual Mock Loop model to evaluate a new left ventricular assist device for transapical insertion. Int J Artif Organs 2020; 43:677-683. [PMID: 32089074 DOI: 10.1177/0391398820907104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We are developing a novel type of miniaturized left ventricular assist device that is configured for transapical insertion. The aim of this study was to assess the performance and function of a new pump by using a Virtual Mock Loop system for device characterization and mapping. The results, such as pressure-flow performance curves, from pump testing in a physical mock circulatory loop were used to analyze its function as a left ventricular assist device. The Virtual Mock Loop system was programmed to mimic the normal heart condition, systolic heart failure, diastolic heart failure, and both systolic and diastolic heart failure, and to provide hemodynamic pressure values before and after the activation of several left ventricular assist device pump speeds (12,000, 14,000, and 16,000 r/min). With pump support, systemic flow and mean aortic pressure increased, and mean left atrial pressure and pulmonary artery pressure decreased for all heart conditions. Regarding high pump-speed support, the systemic flow, aortic pressure, left atrial pressure, and pulmonary artery pressure returned to the level of the normal heart condition. Based on the test results from the Virtual Mock Loop system, the new left ventricular assist device for transapical insertion may be able to ease the symptoms of patients with various types of heart failure. The Virtual Mock Loop system could be helpful to assess pump performance before in vitro bench testing.
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Affiliation(s)
- Yuichiro Kado
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Adams
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony R Polakowski
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Ly HQ, Noly PE, Nosair M, Lamarche Y. When the Complex Meets the High-Risk: Mechanical Cardiac Support Devices and Percutaneous Coronary Interventions in Severe Coronary Artery Disease. Can J Cardiol 2019; 36:270-279. [PMID: 32036868 DOI: 10.1016/j.cjca.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 11/29/2022] Open
Abstract
Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide. Few practice guidelines directly address the issue of revascularization in patients with CAD at higher risk of periprocedural complications. It remains a challenge to appropriately identify the subset of patients with CAD who will require short-term use of mechanical cardiocirculatory support devices (MCSDs) when high-risk (HR) percutaneous coronary intervention (PCI) is required. Issues of the complexity (coronary anatomy and high burden of comorbidities) and risk status (hemodynamic precarity or compromise) need to be considered when considering revascularization in patients. This review will focus on the evolving concept of protected PCI in patients with CAD, and how a balanced, integrated heart-team approach remains the path to optimal patient-centred care in the setting of HR-PCI supported with MCSD.
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Affiliation(s)
- Hung Q Ly
- Interventional Cardiology Service, Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
| | - Pierre-Emmanuel Noly
- Department of Cardiovascular Surgery, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Mohamed Nosair
- Interventional Cardiology Service, Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Yoan Lamarche
- Department of Cardiovascular Surgery, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
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12
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Shamekhi J, Pütz A, Zimmer S, Tiyerili V, Mellert F, Welz A, Fimmers R, Grube E, Nickenig G, Werner N, Sinning JM. Impact of Hemodynamic Support on Outcome in Patients Undergoing High-Risk Percutaneous Coronary Intervention. Am J Cardiol 2019; 124:20-30. [PMID: 31056109 DOI: 10.1016/j.amjcard.2019.03.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/10/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
The use of left-ventricular (LV) hemodynamic support might facilitate high-risk percutaneous coronary interventions (PCI) in patients with complex coronary artery disease. The impact on outcome is a matter of ongoing debate. We assessed the outcome of high-risk patients who underwent protected PCI in comparison to patients who underwent unprotected high-risk PCI. One hundred and thirty nine patients underwent nonemergent high-risk PCI; 24 (17%) patients underwent protected PCI. To address selection bias, we performed a propensity score matched subanalysis. The primary end point was the occurrence of a major adverse cardiac event during the first year. Patients with protected PCI had a higher logistic EuroSCORE (logES) (protected PCI: 19% vs unprotected PCI: 12%; p = 0.01), a higher SYNTAX score (45 vs 36, p = 0.07), and significantly more often reduced LV function (40% vs 55%; p < 0.001). In protected PCI patients, complete revascularization was more often achieved (87% vs 58%, p = 0.007) without the occurrence of death at 30 days of follow-up (0% vs 4%, p = 0.31). After propensity score matching, patients who underwent protected PCI had a similar 1-year major adverse cardiac event rate compared with patients who underwent unprotected PCI (21% vs 17%, p = 0.67), despite significantly higher procedural complexity for example, more often complex left main bifurcation lesions (71% vs 29%; p = 0.004). In conclusion, 1-year outcome of patients who underwent protected PCI was not different from that in patients with less complex procedures without hemodynamic support, despite more complex coronary anatomy, a higher comorbidity burden, and more often reduced LV function.
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13
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Ryan M, Briceno N, Perera D. Mechanical Circulatory Support in the Cardiac Catheterization Laboratory for Cardiogenic Shock. Korean Circ J 2019; 49:197-213. [PMID: 30808071 PMCID: PMC6393319 DOI: 10.4070/kcj.2018.0443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/23/2018] [Indexed: 01/06/2023] Open
Abstract
Despite the development of acute revascularisation, the mortality rate for cardiogenic shock remains around 50%. Mechanical circulatory support devices have long held promise in improving outcomes in shock, but high-quality evidence of benefit has not been forthcoming. In this article we review the currently available devices for treating shock, their physiological effects and the evidence base for their use in practice. We subsequently look ahead within this developing field, including new devices and novel indications for established technology.
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Affiliation(s)
- Matt Ryan
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Natalia Briceno
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK.
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14
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Robbins KS, Krause M, Nguyen AP, Almehlisi A, Meier A, Schmidt U. Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support. J Cardiothorac Vasc Anesth 2019; 33:2814-2825. [PMID: 31060943 DOI: 10.1053/j.jvca.2019.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 12/17/2022]
Abstract
Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.
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Affiliation(s)
- Kimberly S Robbins
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, CA
| | - Martin Krause
- Department of Anesthesiology, Division of Critical Care, University of Colorado, Aurora, CO.
| | - Albert P Nguyen
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, CA
| | - Abdulaziz Almehlisi
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, CA
| | - Angela Meier
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, CA
| | - Ulrich Schmidt
- Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, CA
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15
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Becher T, Eder F, Baumann S, Loßnitzer D, Pollmann B, Behnes M, Borggrefe M, Akin I. Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function. Medicine (Baltimore) 2018; 97:e12665. [PMID: 30412063 PMCID: PMC6221604 DOI: 10.1097/md.0000000000012665] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04-0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.
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Affiliation(s)
- Tobias Becher
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Frederik Eder
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
| | - Stefan Baumann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Dirk Loßnitzer
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Berit Pollmann
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
| | - Michael Behnes
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine-Cardiology, University Medical Centre Mannheim
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
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16
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Desai SR, Hwang NC. Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Ait Ichou J, Larivée N, Eisenberg MJ, Suissa K, Filion KB. The effectiveness and safety of the Impella ventricular assist device for high-risk percutaneous coronary interventions: A systematic review. Catheter Cardiovasc Interv 2017; 91:1250-1260. [PMID: 28941078 DOI: 10.1002/ccd.27316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 07/31/2017] [Accepted: 08/07/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Small randomized controlled trials (RCTs) and observational studies have examined the effectiveness and safety of the Impella device, a percutaneous left ventricular assist device, in the setting of high-risk percutaneous coronary intervention (PCI). However, data are sparse and results are conflicting. Our objective was to evaluate the effectiveness and safety of the Impella device in high-risk patients undergoing PCI via a systematic review of the literature. METHODS We searched Medline, EMBASE, and the Cochrane Library for RCTs and observational studies that evaluated the Impella device in high-risk patients undergoing PCI. Inclusion was restricted to studies in which ≥10 patients received the Impella device; both uncontrolled and controlled (versus intra-aortic-balloon pump [IABP]) studies were included. RESULTS A total of 20 studies (4 RCTs, 2 controlled observational studies, and 14 uncontrolled observational studies; 1,287 patients) were included, with follow-up ranging from 1 to 42 months. The use of Impella resulted in improved procedural and hemodynamic characteristics in controlled and uncontrolled studies. In controlled studies, the 30-day rates of all-cause mortality and MACE were similar across groups. In most uncontrolled studies, the 30-day rates of all-cause mortality were generally low (range: 3.7%-10%), though rates of MACE were slightly higher (range: 5%-20%). CONCLUSION The Impella device was found to improve procedural and hemodynamic parameters, but only limited randomized data are available regarding clinical outcomes associated with its use. Large, multicenter RCTs are needed to definitively establish the effectiveness of the Impella device among high-risk PCI patients.
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Affiliation(s)
- Jamal Ait Ichou
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Natasha Larivée
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
| | - Karine Suissa
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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18
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Tepper S, Masood MF, Baltazar Garcia M, Pisani M, Ewald GA, Lasala JM, Bach RG, Singh J, Balsara KR, Itoh A. Left Ventricular Unloading by Impella Device Versus Surgical Vent During Extracorporeal Life Support. Ann Thorac Surg 2017; 104:861-867. [DOI: 10.1016/j.athoracsur.2016.12.049] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/18/2016] [Accepted: 12/23/2016] [Indexed: 01/12/2023]
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19
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Meraj PM, Doshi R, Schreiber T, Maini B, O'Neill WW. Impella 2.5 initiated prior to unprotected left main PCI in acute myocardial infarction complicated by cardiogenic shock improves early survival. J Interv Cardiol 2017; 30:256-263. [DOI: 10.1111/joic.12377] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
| | - Rajkumar Doshi
- Department of Cardiology; Northwell Health; Manhasset New York
| | | | - Brijeshwar Maini
- Department of Interventional Cardiology and Transcatheter Therapy; Charles E. Schmidt College of Medicine; Delray Beach Florida
| | - William W. O'Neill
- Department of Interventional Cardiology and Structural Heart; Henry Ford Medical Center; Detroit Michigan
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20
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Flaherty MP, Pant S, Patel SV, Kilgore T, Dassanayaka S, Loughran JH, Rawasia W, Dawn B, Cheng A, Bartoli CR. Hemodynamic Support With a Microaxial Percutaneous Left Ventricular Assist Device (Impella) Protects Against Acute Kidney Injury in Patients Undergoing High-Risk Percutaneous Coronary Intervention. Circ Res 2017; 120:692-700. [DOI: 10.1161/circresaha.116.309738] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/31/2016] [Accepted: 01/10/2017] [Indexed: 01/25/2023]
Abstract
Rationale:
Acute kidney injury (AKI) is common during high-risk percutaneous coronary intervention (PCI), particularly in those with severely reduced left ventricular ejection fraction. The impact of partial hemodynamic support with a microaxial percutaneous left ventricular assist device (pLVAD) on renal function after high-risk PCI remains unknown.
Objective:
We tested the hypothesis that partial hemodynamic support with the Impella 2.5 microaxial pLVAD during high-risk PCI protected against AKI.
Methods and Results:
In this retrospective, single-center study, we analyzed data from 230 patients (115 consecutive pLVAD-supported and 115 unsupported matched-controls) undergoing high-risk PCI with ejection fraction ≤35%. The primary outcome was incidence of in-hospital AKI according to AKI network criteria. Logistic regression analysis determined the predictors of AKI. Overall, 5.2% (6) of pLVAD-supported patients versus 27.8% (32) of unsupported control patients developed AKI (
P
<0.001). Similarly, 0.9% (1) versus 6.1% (7) required postprocedural hemodialysis (
P
<0.05). Microaxial pLVAD support during high-risk PCI was independently associated with a significant reduction in AKI (adjusted odds ratio, 0.13; 95% confidence intervals, 0.09–0.31;
P
<0.001). Despite preexisting CKD or a lower ejection fraction, pLVAD support protection against AKI persisted (adjusted odds ratio, 0.63; 95% confidence intervals, 0.25–0.83;
P
=0.04 and adjusted odds ratio, 0.16; 95% confidence intervals, 0.12–0.28;
P
<0.001, respectively).
Conclusions:
Impella 2.5 (pLVAD) support protected against AKI during high-risk PCI. This renal protective effect persisted despite the presence of underlying CKD and decreasing ejection fraction.
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Affiliation(s)
- Michael P. Flaherty
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Sadip Pant
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Samir V. Patel
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Tyler Kilgore
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Sujith Dassanayaka
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - John H. Loughran
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Wasiq Rawasia
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Buddhadeb Dawn
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Allen Cheng
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
| | - Carlo R. Bartoli
- From the Cardiovascular Medicine, University of Louisville School of Medicine, KY (M.P.F., S.P., T.K., S.D., J.H.L., W.R.); Internal Medicine, Sparks Regional Medical Center, Fort Smith, AR (S.V.P.); Cardiology, University of Kansas Medical Center, Kansas City (B.D.); Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (A.C.); and Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia (C.R.B.)
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21
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Kahaly O, Boudoulas KD. Percutaneous left ventricular assist device in high risk percutaneous coronary intervention. J Thorac Dis 2016; 8:298-302. [PMID: 27076921 DOI: 10.21037/jtd.2016.01.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Omar Kahaly
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Konstantinos Dean Boudoulas
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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22
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Whitson BA. Surgical implant techniques of left ventricular assist devices: an overview of acute and durable devices. J Thorac Dis 2016; 7:2097-101. [PMID: 26793329 DOI: 10.3978/j.issn.2072-1439.2015.11.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Left ventricular support for the failing heart has evolved to include short-term and long-term devices. These devices are implanted percutaneously and surgically. This manuscript provides a general overview of the contemporary, typically practiced, implant techniques with additional insight on minimally invasive approaches.
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Affiliation(s)
- Bryan A Whitson
- Department of Surgery, Division of Cardiac Surgery, Ohio State University Medical Center, Columbus, OH 43210, USA
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23
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Abaunza M, Kabbani LS, Nypaver T, Greenbaum A, Balraj P, Qureshi S, Alqarqaz MA, Shepard AD. Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device. J Vasc Surg 2015; 62:417-23. [DOI: 10.1016/j.jvs.2015.03.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/18/2015] [Indexed: 11/25/2022]
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24
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Spiro J, Doshi SN. Use of left ventricular support devices during acute coronary syndrome and percutaneous coronary intervention. Curr Cardiol Rep 2015; 16:544. [PMID: 25326728 DOI: 10.1007/s11886-014-0544-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In an effort to improve outcomes in percutaneous coronary intervention (PCI), percutaneous ventricular assist devices (PVADs) have been investigated in (1) high-risk PCI, (2) acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) and (3) in AMI without CS. PCI has become an increasing complex due to an ageing population with complex disease and the frequent presence of impaired LV function. Patients undergoing high-risk PCI in these circumstances are prone to acute cardiovascular collapse. Additionally, mortality in AMI complicated by CS remains high. Lastly, LV support during AMI may reduce infarct size and therefore preserve LV function. At present, four commercially available devices exist: intra-aortic balloon pump counterpulsation (IABP), Impella, TandemHeart and extracorporeal membrane oxygenation (ECMO). These devices are employed in an effort to increase cardiac output, mean arterial pressure (MAP) and coronary perfusion and to reduce pulmonary capillary wedge pressure (PCWP). The mechanism of action differs with each device, and there are advantages and disadvantages. In this update, we discuss recent data describing the use of PVADs to support patients with AMI with or without cardiogenic shock and during high-risk PCI. We focus on the unique features of each device, highlighting strengths, weaknesses and frequently encountered complications, which may be important when tailoring the most appropriate PVAD therapy to an individual patient's need.
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Affiliation(s)
- Jon Spiro
- Department of Cardiology, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
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25
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Frisoli TM, Guerrero M, O'Neill WW. Mechanical circulatory support with impella to facilitate percutaneous coronary intervention for post-TAVI bilateral coronary obstruction. Catheter Cardiovasc Interv 2015; 88:E34-7. [PMID: 26104838 DOI: 10.1002/ccd.26075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 05/23/2015] [Indexed: 11/07/2022]
Abstract
One of the potential complications of transcatheter aortic valve implantation (TAVI) is coronary obstruction (CO), which can occur by displacement of heavily calcified native valve cusps against the coronary ostium. Treatment mandates immediate percutaneous coronary intervention (PCI) to restore coronary flow and improve hemodynamics and if unsuccessful, urgent implementation of circulatory support, commonly extracorporeal, with subsequent surgical revascularization. We report a case of post-TAVI CO for which successful emergent deployment of Impella percutaneous mechanical circulatory support to restore hemodynamic stability facilitated definitive treatment with bilateral PCI. Impella support represents an expeditious, effective, and widely available therapy to complement and facilitate PCI in the treatment of CO complicating TAVI, and may diminish requirement for urgent coronary artery bypass surgery. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Tiberio M Frisoli
- Division of Cardiology, Henry Ford Health System, Heart and Vascular Institute, Detroit, Michigan
| | - Mayra Guerrero
- Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
| | - William W O'Neill
- Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
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26
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Gilani FS, Farooqui S, Doddamani R, Gruberg L. Percutaneous Mechanical Support in Cardiogenic Shock: A Review. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:23-8. [PMID: 26052235 PMCID: PMC4448941 DOI: 10.4137/cmc.s19707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/09/2015] [Accepted: 04/28/2015] [Indexed: 01/06/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. Pharmacological therapy is often the first line of treatment but mechanical support can provide substantial hemodynamic improvement in refractory CS. Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance to the failing myocardium. We review the percutaneous devices currently available, the evidence behind their use, and the new advances in percutaneous technology being evaluated for the treatment of CS.
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Affiliation(s)
- Fahad Syed Gilani
- Division of Cardiovascular Medicine, Boston University School of Medicine, Boston Medical Center. Boston, MA, USA
| | - Sarah Farooqui
- Division of Cardiovascular Medicine, Boston University School of Medicine, Boston Medical Center. Boston, MA, USA
| | - Rajiv Doddamani
- Division of Cardiovascular Medicine, Boston University School of Medicine, Boston Medical Center. Boston, MA, USA
| | - Luis Gruberg
- Division of Cardiovascular Disease, Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
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27
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Percutaneous Mechanical Ventricular Support in Acute Cardiac Care: A UK Quaternary Centre Experience Using 2.5L, 3.8L and 5.0L Impella Catheters. Cardiol Ther 2014; 4:47-58. [PMID: 25515965 PMCID: PMC4472647 DOI: 10.1007/s40119-014-0033-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Indexed: 02/02/2023] Open
Abstract
Aims The Impella is a percutaneous ventricular assist device. The majority of published data describes the 2.5L and 5.0L devices, and little data is available for the newer 3.8L device. We examined the indications and outcomes from our single-centre “real-world” registry at The Queen Elizabeth Hospital, Birmingham, UK, using all three pump sizes. Methods and Results Records from all patients who underwent attempted Impella-assisted procedures at our centre were examined retrospectively. Impella implantation was attempted in 49 patients (mean age 72 ± 13 years; 80% male) and was successful in 48 (98%). 45 patients underwent high-risk percutaneous coronary intervention (PCI), one patient underwent balloon aortic valvuloplasty and 3 patients had Impella as a bridge to cardiac transplantation. The 2.5L and 3.8L devices were used in 36 (75%) and 11 (23%) patients, respectively, while one patient (2%) had the 5L device. Vascular complications occurred in only one patient (2%) and stroke and peri-procedural myocardial infarction occurred in one patient (2%), while in-hospital mortality was 20% (10/49). Conclusions In this large real-world registry, we have demonstrated the safety and feasibility of the Impella device for a wide range of indications. This includes the first series of the 3.8L device which provides superior support with no increase in vascular complications. Electronic supplementary material The online version of this article (doi:10.1007/s40119-014-0033-8) contains supplementary material, which is available to authorized users.
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28
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Heidlebaugh M, Kurz MC, Turkelson CL, Sawyer KN. Full neurologic recovery and return of spontaneous circulation following prolonged cardiac arrest facilitated by percutaneous left ventricular assist device. Ther Hypothermia Temp Manag 2014; 4:168-72. [PMID: 25184627 DOI: 10.1089/ther.2014.0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Sudden cardiac arrest is associated with high early mortality, which is largely related to postcardiac arrest syndrome characterized by an acute but often transient decrease in left ventricular (LV) function. The stunned LV provides poor cardiac output, which compounds the initial global insult from hypoperfusion. If employed early, an LV assist device (LVAD) may improve survival and neurologic outcome; however, traditional methods of augmenting LV function have significant drawbacks, limiting their usefulness in the periarrest period. Full cardiac support with cardiopulmonary bypass is not always readily available but is increasingly being studied as a tool to intensify resuscitation. There have been no controlled trials studying the early use of percutaneous LVADs (pLVADs) in pericardiac arrest patients or intra-arrest as a bridge to return of spontaneous circulation. This article presents a case study and discussion of a patient who arrested while undergoing an elective coronary angioplasty and suffered prolonged cardiopulmonary resuscitation. During resuscitation, treatment included placement of a pLVAD and initiation of therapeutic hypothermia. The patient made a rapid and full recovery.
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Affiliation(s)
- Michael Heidlebaugh
- 1 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
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Henriques JP, Ouweneel DM, Naidu SS, Palacios IF, Popma J, Ohman EM, O'Neill WW. Evaluating the learning curve in the prospective Randomized Clinical Trial of hemodynamic support with Impella 2.5 versus Intra-Aortic Balloon Pump in patients undergoing high-risk percutaneous coronary intervention: a prespecified subanalysis of the PROTECT II study. Am Heart J 2014; 167:472-479.e5. [PMID: 24655695 DOI: 10.1016/j.ahj.2013.12.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 12/23/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The introduction of new medical devices may be accompanied by a learning curve. METHODS To evaluate the impact of the device learning curve on the outcomes of PROTECT II trial, comparing Impella 2.5 versus the intra-aortic balloon pump (IABP) during high-risk percutaneous coronary intervention, we report on a prespecified analysis, excluding the first Impella 2.5 and IABP patients at each site. RESULTS A total of 448 patients were enrolled at 74 sites. Among these, 58 patients were the first to receive Impella 2.5 at their site, 62 were the first to receive IABP. A trend toward higher major adverse events (MAEs) at 30 days was observed for the subgroup of first versus remaining Impella 2.5 patients: 44.8% versus 31.7%, P = .072. MAE rates for the first and remaining IABP patients were similar at 30 days. After exclusion of the first patient in each group, MAE rates for Impella 2.5 and IABP were 31.7% versus 40.0% (P = .119) at 30 days and 38.0% versus 50.0% (P = .029) at 90 days. CONCLUSIONS Significantly lower 90-day MAE rates were observed with the use of Impella 2.5 compared to the use of IABP after excluding the first patient per group at each site. This prespecified analysis suggests a learning curve associated with initial introduction of the Impella 2.5. Clinical trials should better address the training aspect of new devices, especially when compared with more established devices.
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Aggarwal S, Slaughter MS. Acute myocardial infarction complicated by cardiogenic shock: role of mechanical circulatory support. Expert Rev Cardiovasc Ther 2014; 6:1223-35. [DOI: 10.1586/14779072.6.9.1223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Economic and Operational Implications of a Standardized Approach to Hemodynamic Support Therapy Using Percutaneous Cardiac Assist Devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:38-42. [DOI: 10.1097/imi.0000000000000047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Impella 2.5 has been shown to reduce major adverse events for patients undergoing elective high-risk percutaneous coronary intervention. We performed a single-center retrospective study to compare the costs and resource use of Impella 2.5 and intra-aortic balloon pump (IABP) support. Methods All high-risk patients who received Impella 2.5 (n = 35) and IABP (n = 295) support from December 2008 to July 2011 were included. Propensity score matching identified a balanced 1:1 matched cohort (35 Impella vs 35 IABP) based on indications for implantation, preimplantation hemodynamics, and age. Diagnostic, procedural, financial, and resource use data were collected. Results As compared with IABP, Impella offered a more predictable course of treatment/resource consumption and was not associated with any extreme cost outliers (17.1% vs 0.0%, respectively; P = 0.025). The mean admission and 90-day episode of care total costs for Impella were 5.5% ($67,681 vs $71,608, P = 0.79) and 4.2% ($70,680 vs $73,476, P = 0.85) lesser than that for IABP, respectively. Although not statistically significant, Impella patients had a trend toward lower rehospitalization rates (11.4% vs 20%), lesser mean index length of hospital stay (11.2 vs 13.7), and 90-day (11.7 vs 14.2) episode of care length of hospital stay. Conclusions Impella support was associated with consistent course of treatment/resource consumption with significantly fewer 90-day extreme cost outliers than was IABP. The lower index and 90-day follow-up cost trends observed for Impella were driven by shorter length of hospital stay and fewer rehospitalizations. As providers strive to improve quality of care by reducing variability, these findings have implications for the development of hemodynamic support algorithms.
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Wohns D, Muthusamy P, Davis AT, Khan M, Postma JK, Williams EE, Gile CM, Scotti DJ, Gregory D. Economic and Operational Implications of a Standardized Approach to Hemodynamic Support Therapy Using Percutaneous Cardiac Assist Devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014. [DOI: 10.1177/155698451400900107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David Wohns
- Division of Interventional Cardiology, Department of Cardiology, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI USA
- Division of Cardiology, Spectrum Health, Grand Rapids, MI USA
| | - Purushothaman Muthusamy
- Internal Medicine Residency, Grand Rapids Medical Education Partners/Michigan State University Program, Grand Rapids, MI USA
| | - Alan T. Davis
- Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI USA
- Department of Surgery, Michigan State University, Grand Rapids, MI USA
| | - Mohsin Khan
- Internal Medicine Hospitalist, Spectrum Health, Grand Rapids, MI USA
| | - Joseph K. Postma
- Internal Medicine Residency, Grand Rapids Medical Education Partners/Michigan State University Program, Grand Rapids, MI USA
| | - Elbert E. Williams
- Michigan State University-College of Human Medicine, East Lansing, MI USA
| | - Cynthia M. Gile
- Department of Research, Spectrum Health, Grand Rapids, MI USA
| | - Dennis J. Scotti
- Department of Management, Fairleigh Dickinson University, Teaneck, NJ USA
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Abstract
Improving myocyte salvage during acute myocardial infarction (AMI) has proved elusive; the keys to success seem to be the ability to lower oxygen demand of ischemic myocardium and also activate salvage enzyme pathways to take advantage of endogenous cardioprotective mechanisms. Pharmacologic approaches have been largely unsuccessful. A percutaneous left ventricular (LV) assist device could improve myocyte salvage during AMI therapy if it were able to reduce myocardial oxygen demand, wall tension, and LV stroke work substantially.
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Affiliation(s)
- Hammad Saudye
- Department of Cardiology, Northshore-LIJ/Lenox Hill Hospital, New York, NY 10075, USA
| | - Kirk N Garratt
- Department of Cardiology, Northshore-LIJ/Lenox Hill Hospital, New York, NY 10075, USA.
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Abstract
Persistent cardiac arrest is often caused by coronary ischemia. Urgent revascularization during on-going resuscitation with the support of percutaneous left ventricular assist devices (PVAD) may be feasible and can have the potential to improve the prognosis. Transport during resuscitation is a challenge that may be overcome with the use of cardiopulmonary resuscitation devices. In the catheterization laboratory, rapid deployment of PVAD may reduce ischemia, contribute to electrical stabilization of the heart, and facilitate definite treatment with percutaneous coronary intervention. After revascularization, PVAD therapy may promote myocardial recovery and improve vital organ perfusion in a critical phase.
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Boudoulas KD, Pederzolli A, Saini U, Gumina RJ, Mazzaferri EL, Davis M, Bush CA, Capers Q, Magorien R, Pompili VJ. Comparison of Impella and intra-aortic balloon pump in high-risk percutaneous coronary intervention: vascular complications and incidence of bleeding. ACTA ACUST UNITED AC 2013; 14:120-4. [PMID: 23215746 DOI: 10.3109/17482941.2012.741244] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Compare vascular complications and incidence of bleeding of Impella 2.5 and intra-aortic balloon pump (IABP) in high-risk percutaneous coronary interventions (PCI). BACKGROUND Large arterial sheath size for device insertion is associated with vascular and/or bleeding complications; gastrointestinal bleeding may also occur with anti-coagulation use. METHODS Patients with an acute coronary syndrome receiving Impella 2.5 or IABP during high-risk PCI were studied (13 Impella; 62 IABP). Vascular complications and incidence of bleeding were compared. RESULTS Post-procedure hematocrit was similar between groups. Blood transfusion occurred in 38.4% and 32.2% of patients in the Impella and IABP groups, respectively (P = NS); 65.3%, 30.7% and 3.8% of bleeding were due to vascular access site/procedure related, gastrointestinal and genitourinary, respectively. There was no statistical significant difference in vascular complications between the Impella and IABP groups (15.3% and 6.4% of patients, respectively); mesenteric ischemia (n = 1) and aortic rupture (n = 1) were only in the IABP group. In-hospital and one-year mortality were not statistically significant between groups. CONCLUSION Impella can be used as safely as IABP during high-risk PCI with similar vascular and bleeding complications. Importantly, approximately one third of bleeding was from the gastrointestinal system warranting careful prophylactic measures and monitoring.
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Affiliation(s)
- Konstantinos Dean Boudoulas
- Division of Cardiovascular Medicine, Section of Interventional Cardiology, The Ohio State University, Columbus, Ohio 43210, USA.
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Kovacic JC, Nguyen HT, Karajgikar R, Sharma SK, Kini AS. The Impella Recover 2.5 and TandemHeart ventricular assist devices are safe and associated with equivalent clinical outcomes in patients undergoing high-risk percutaneous coronary intervention. Catheter Cardiovasc Interv 2013; 82:E28-37. [PMID: 21234916 DOI: 10.1002/ccd.22929] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 11/27/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the practical use, safety, and clinical outcomes associated with the TandemHeart (TH) versus Impella Recover 2.5 (IR2.5) devices when used for circulatory support during high-risk percutaneous coronary intervention (PCI). BACKGROUND Small studies and registries suggest safety and efficacy for the TH and IR2.5 percutaneous-left ventricular assist devices (P-LVADs). However, these P-LVADs differ markedly in their insertion, operation, and manner of circulatory augmentation. To date, no study has compared these devices. METHODS We identified 68 patients (49 males, 19 females; age 71.1 ± 12.1 years) from our single-center database that underwent "high-risk" PCI with P-LVAD support from April 2005 to June 2010 (32 with TH, 36 with IR2.5). Relevant data were extracted for analysis. RESULTS Baseline demographics were similar, including low LVEF (overall mean 31.0 ± 13.7%) and elevated STS mortality risk score (4.2 ± 3.7%). Angiographic characteristics were also similar, with a mean of 2.4 ± 1.0 lesions treated per patient, and 29% undergoing left main PCI. PCI success rates were 99% in both groups, with similar in-hospital outcomes and a combined 7% major vascular access site complication rate. A single episode of left atrial perforation occurred during TH use. No patient required emergent CABG and no in-hospital deaths occurred. The 30-day MACE rate (death, myocardial infarction, target lesion revascularization) was 5.8%. There were no differences between the IR2.5 and TH groups with respect to short- or long-term clinical outcomes. CONCLUSIONS The IR2.5 and TH assist devices are safe, equally effective, and associated with acceptable short- and long-term clinical outcomes in patients undergoing "high-risk" PCI.
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Affiliation(s)
- Jason C Kovacic
- Cardiac Catheterization Laboratory, Cardiovascular Institute, Mount Sinai Hospital, New York, New York 10029, USA
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Impella 2.5 in a patient with left main coronary artery occlusion. J Cardiol Cases 2013; 7:e142-e144. [PMID: 30533147 DOI: 10.1016/j.jccase.2013.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/30/2012] [Accepted: 01/03/2013] [Indexed: 11/22/2022] Open
Abstract
Short-term assist devices have been indicated in many clinical settings mostly as a bridge to the next step. In this article, we report a case of cardiogenic shock due to acute occlusion of left main coronary artery who was scheduled to be transferred from Iran to Germany for the next treatment (permanent assist device implantation). Impella 2.5 (Abiomed Inc., Danvers, MA, USA), a short-term assist device, made the long distance journey possible. <Learning objective: Managing of severe cardiogenic shock by early revascularization and prompt installation of mechanical circulatory support in peripheral hospital as bridge to decision and successful long-distance transfer on mechanical circulatory support.>.
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Manzo-Silberman S, Fichet J, Mathonnet A, Varenne O, Ricome S, Chaib A, Zuber B, Spaulding C, Cariou A. Percutaneous left ventricular assistance in post cardiac arrest shock: comparison of intra aortic blood pump and IMPELLA Recover LP2.5. Resuscitation 2012; 84:609-15. [PMID: 23069592 DOI: 10.1016/j.resuscitation.2012.10.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/27/2012] [Accepted: 10/02/2012] [Indexed: 12/21/2022]
Abstract
AIM To compare the feasibility, safety and outcome of IMPELLA Recover LP2.5 cardiac assistance and intra aortic balloon pump (IABP) in patients with post-cardiac arrest shock. BACKGROUND The high early mortality rate of post-cardiac arrest patients is attributed to a "post cardiac arrest syndrome" characterized by an acute and transient left ventricular (LV) systolic dysfunction. LV assistance with IMPELLA Recover LP2.5 is proposed in most severe patients. METHODS Retrospective single center registry from January 2007 to October 2010. All survivors of out-of-hospital cardiac arrest with patent or predictive factors for the occurrence of post-resuscitation shock assisted by either IMPELLA or intra aortic balloon pump (IABP) device immediately after the coronary angiogram were included. RESULTS 78 post-cardiac arrest patients were assisted by one of the devices (35 by IMPELLA and 43 by IABP). Median "no flow" and median "low flow" were similar at admission as were hemodynamic parameters. The feasibility of IMPELLA implantation was good (97%). At 28 days, the survival rate without sequellae was 23.0% in the IMPELLA and 29.5% in the IABP group (p=0.61). Vascular complications were observed equally in both groups (3 vs. 2, p=0.9). Serious bleeding complications occurred in 26% of IMPELLA patients vs. 9% of IABP patients (p=0.06). CONCLUSION Early LV assistance by the IMPELLA LP2.5 is feasible in patients with post-resuscitation shock. The rate of complications did not differ substantially in the two groups, except for a trend toward a higher rate of bleeding events with IMPELLA. These encouraging findings must be confirmed in a larger clinical study.
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Affiliation(s)
- Stéphane Manzo-Silberman
- Cardiology Department, Cochin University Hospital (AP-HP) & Paris Descartes University (Medical School), 27 Rue du Faubourg Saint Jacques, 75014 Paris, France.
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Sharma AB, Kovacic JC, Kini AS. Percutaneous Left Ventricular Assist Devices. Interv Cardiol Clin 2012; 1:609-622. [PMID: 28581973 DOI: 10.1016/j.iccl.2012.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Percutaneous left ventricular assist devices (P-LVADs) can be life saving and may permit the stabilization of a patient in cardiovascular collapse who would otherwise face imminent demise. For specific patients and clinical indications, or where a greater degree of hemodynamic support is required, numerous studies have demonstrated the feasibility and safety of the newer generation P-LVADs. The potential applications for P-LVADs have continued to expand, now including diverse uses such as support for cardiogenic shock, bridge to and following cardiac surgery, and more novel applications such as complex electrophysiologic mapping and ablation studies of unstable ventricular rhythms.
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Affiliation(s)
- Amit B Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Jason C Kovacic
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Annapoorna S Kini
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA.
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Mukku VK, Cai Q, Gilani S, Fujise K, Barbagelata A. Use of impella ventricular assist device in patients with severe coronary artery disease presenting with cardiac arrest. Int J Angiol 2012; 21:163-6. [PMID: 23997562 PMCID: PMC3578627 DOI: 10.1055/s-0032-1324736] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Impella (Abiomed, Danvers, MA) is a percutaneously inserted ventricular assist device (VAD). It has been increasingly used in patients with severe heart failure, cardiogenic shock, and high-risk percutaneous intervention (PCI). However, the use and efficacy of Impella in patients with severe coronary artery disease (CAD) presenting with cardiac arrest has rarely been reported.The objective of this study is to report our center experience in using Impella VAD in CAD patients presenting with cardiac arrest. From December 2010 to March 2011, three patients with severe CAD presented to our center with cardiac arrest underwent PCI with Impella support. We reported three cases of severe CAD presenting with cardiac arrest successfully treated with PCI and Impella support. Our experience demonstrated that Impella VAD may play an adjunctive role in obtaining hemodynamic stability in these high-risk patients undergoing PCI. One of the patients was supported to left VAD implantation, and the other two had excellent neurological and functional recovery. Our reports suggest an important role of Impella in cardiac arrest population. Earlier Impella implantation after cardiac arrest might provide cardiac support and tissue perfusion until recovery or high-risk PCI.
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Affiliation(s)
- Venkata K. Mukku
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Qiangjun Cai
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Syed Gilani
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Ken Fujise
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
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O'Neill WW, Kleiman NS, Moses J, Henriques JPS, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma J, Douglas PS, Ohman M. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation 2012; 126:1717-27. [PMID: 22935569 DOI: 10.1161/circulationaha.112.098194] [Citation(s) in RCA: 574] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although coronary artery bypass grafting is generally preferred in symptomatic patients with severe, complex multivessel, or left main disease, some patients present with clinical features that make coronary artery bypass grafting clinically unattractive. Percutaneous coronary intervention with hemodynamic support may be feasible for these patients. Currently, there is no systematic comparative evaluation of hemodynamic support devices for this indication. METHODS AND RESULTS We randomly assigned 452 symptomatic patients with complex 3-vessel disease or unprotected left main coronary artery disease and severely depressed left ventricular function to intra-aortic balloon pump (IABP) (n=226) or Impella 2.5 (n=226) support during nonemergent high-risk percutaneous coronary intervention. The primary end point was the 30-day incidence of major adverse events. A 90-day follow-up was required, as well, by protocol. Impella 2.5 provided superior hemodynamic support in comparison with IABP, with maximal decrease in cardiac power output from baseline of -0.04±0.24 W in comparison with -0.14±0.27 W for IABP (P=0.001). The primary end point (30-day major adverse events) was not statistically different between groups: 35.1% for Impella 2.5 versus 40.1% for IABP, P=0.227 in the intent-to-treat population and 34.3% versus 42.2%, P=0.092 in the per protocol population. At 90 days, a strong trend toward decreased major adverse events was observed in Impella 2.5-supported patients in comparison with IABP: 40.6% versus 49.3%, P=0.066 in the intent-to-treat population and 40.0% versus 51.0%, P=0.023 in the per protocol population, respectively. CONCLUSIONS The 30-day incidence of major adverse events was not different for patients with IABP or Impella 2.5 hemodynamic support. However, trends for improved outcomes were observed for Impella 2.5-supported patients at 90 days. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00562016.
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Affiliation(s)
- William W O'Neill
- Division of Cardiology, Department of Internal Medicine, Leonard M Miller School of Medicine, 1600 NW 10th Ave, Miami, FL 33156, USA.
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Chandola R, Cusimano R, Osten M, Horlick E. Severe Aortic Insufficiency Secondary to 5L Impella Device Placement. J Card Surg 2012; 27:400-2. [DOI: 10.1111/j.1540-8191.2012.01454.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Maini B, Naidu SS, Mulukutla S, Kleiman N, Schreiber T, Wohns D, Dixon S, Rihal C, Dave R, O'Neill W. Real-world use of the Impella 2.5 circulatory support system in complex high-risk percutaneous coronary intervention: The USpella Registry. Catheter Cardiovasc Interv 2012; 80:717-25. [DOI: 10.1002/ccd.23403] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 10/02/2011] [Indexed: 12/11/2022]
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Cubeddu R, Lago R, Horvath S, Vignola P, O’Neill W, Palacios I. Use of the Impella 2.5 system alone, after and in combination with an intra-aortic balloon pump in patients with cardiogenic shock: case description and review of the literature. EUROINTERVENTION 2012; 7:1453-60. [DOI: 10.4244/eijv7i12a226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Use of the Impella 2.5 for prophylactic circulatory support during elective high-risk percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:299-303. [DOI: 10.1016/j.carrev.2011.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 02/02/2011] [Accepted: 02/04/2011] [Indexed: 11/22/2022]
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Bresson D, Sibellas F, Farhat F, Jegaden O, Kirkorian G, Bonnefoy E. Preliminary experience with Impella Recover(®) LP5.0 in nine patients with cardiogenic shock: a new circulatory support system in the intensive cardiac care unit. Arch Cardiovasc Dis 2011; 104:458-64. [PMID: 21944148 DOI: 10.1016/j.acvd.2011.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Revised: 04/12/2011] [Accepted: 04/13/2011] [Indexed: 11/19/2022]
Abstract
AIM Cardiogenic shock is associated with high mortality. We report our experience with the short-term left ventricular axial pump Impella LP5.0 in nine patients with severe ischaemic heart failure. METHODS Six patients (group 1) presented with cardiogenic shock at the acute phase of an ST elevation myocardial infarction. Three patients (group 2) had severe ischaemic cardiomyopathy with temporary contra-indication to LVAD or transplantation. We measured haemodynamic and metabolic variables up to 96hours and recorded morbidity, mechanical pump failures, and mortality up to one year postimplantation. RESULTS In all patients the Impella LP5.0 was safely placed through the right subclavian artery. Cardiac power output increased from 0.64 (0.07) W to 0.94 (0.44) W and 1.02 (0.30) W at 24 and 72hours, respectively. The Impella LP5.0 remained in place for 12 (7.2) days. In group 1, five patients were in INTERMACS Profile 3 at the time of pump insertion. Three could be weaned and survived. One patient in INTERMACS Profile 1 died of intractable heart failure within hours. In group 2, two of three patients underwent heart transplantation. Haemorrhage requiring transfusions was observed in four patients but only one case was directly related to the Impella LP5.0. CONCLUSION Left ventricular assistance with the Impella LP5.0 appears to be well tolerated. It may be especially useful in patients with acute myocardial infarction complicated by cardiogenic shock who achieve INTERMACS Profile 3 with initial treatment.
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Affiliation(s)
- Didier Bresson
- Intensive Cardiac Care Unit, Hospices Civils de Lyon, France
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Engström AE, Engström A, Sjauw KD, Sjauw K, Baan J, Remmelink M, Claessen BEPM, Claessen B, Kikkert WJ, Kikkert W, Hoebers LPC, Hoebers L, Vis MM, Vis M, Koch KT, Koch K, Meuwissen MM, Meuwissen M, Tijssen JGP, Tijssen J, De Winter RJ, De Winter R, Piek JJ, Piek J, Henriques JPS, Henriques J. Long-term safety and sustained left ventricular recovery: long-term results of percutaneous left ventricular support with Impella LP2.5 in ST-elevation myocardial infarction. EUROINTERVENTION 2011; 6:860-5. [PMID: 21252021 DOI: 10.4244/eijv6i7a147] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Mechanical left ventricular (LV) unloading may reduce infarct size when combined with primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). The Impella LP2.5 is a novel percutaneous left ventricular assist device. Although the short-term safety and feasibility of this device have been demonstrated, the long-term effects are unknown. The purpose of the current study was to evaluate the long-term effects of the Impella LP2.5 support on the aortic valve and left ventricular ejection fraction (LVEF). METHODS AND RESULTS In 2006, 10 patients with anterior STEMI received 3-day support with the Impella LP2.5 after PCI. The control group consisted of 10 comparable patients, treated according to routine care. For the current study, echocardiography was performed and adverse events were recorded. Mean duration of follow-up was 2.9±0.6 years in the Impella group and 3.0±0.3 years in the control group. No differences in aortic valve abnormalities and LVEF were demonstrated between the groups; nevertheless, LVEF increase from baseline was significantly greater in Impella-treated patients (23.6±8.9% versus 6.7±7.0%, P=0.008). CONCLUSIONS Three-day support with the Impella LP2.5 is not associated with adverse effects on the aortic valve at long-term follow-up. LVEF was similar in both groups; however, recovery was significantly greater in the Impella group.
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Lilli A, Vecchio S, Chechi T, Vittori G, Giuliani G, Spaziani G, Consoli L, Giannotti F, Baldereschi G, Margheri M. Left ventricular support device for cardiogenic shock during myocardial infarction due to stent thrombosis: A single centre experience. Int J Cardiol 2011; 148:337-40. [DOI: 10.1016/j.ijcard.2009.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/11/2009] [Accepted: 11/29/2009] [Indexed: 11/26/2022]
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Edmond J, Baumbach A. The Management of Cardiogenic Shock. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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