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Fujimoto Y, Sakakura K, Fujita H. Complex and high-risk intervention in indicated patients (CHIP) in contemporary clinical practice. Cardiovasc Interv Ther 2023:10.1007/s12928-023-00930-1. [DOI: 10.1007/s12928-023-00930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
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2
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Hennessey B, Pareek N, Macaya F, Yeoh J, Shlofmitz E, Gonzalo N, Hill J, Escaned J. Contemporary percutaneous management of coronary calcification: current status and future directions. Open Heart 2023; 10:openhrt-2022-002182. [PMID: 36796870 PMCID: PMC9936324 DOI: 10.1136/openhrt-2022-002182] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/20/2023] [Indexed: 02/18/2023] Open
Abstract
Severe coronary artery calcification is one of the greatest challenges in attaining success in percutaneous coronary intervention, limiting acute and long-term results. In many cases, plaque preparation is a critical prerequisite for delivery of devices across calcific stenoses and also to achieve adequate luminal dimensions. Recent advances in intracoronary imaging and adjunctive technologies now allow the operator to select the most appropriate strategy in each individual case. In this review, we will revisit the distinct advantages of a complete assessment of coronary artery calcification with imaging and application of appropriate and contemporary plaque modification technologies in achieving durable results in this complex lesion subset.
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Affiliation(s)
- Breda Hennessey
- Hospital Clinico San Carlos Instituto Cardiovascular, Madrid, Comunidad de Madrid, Spain
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, UK .,School of Cardiovascular Medicine & Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Fernando Macaya
- Hospital Clinico San Carlos Instituto Cardiovascular, Madrid, Comunidad de Madrid, Spain.,King's College Hospital NHS Foundation Trust, London, UK
| | - Julian Yeoh
- King's College Hospital NHS Foundation Trust, London, UK.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Nieves Gonzalo
- Hospital Clinico San Carlos Instituto Cardiovascular, Madrid, Comunidad de Madrid, Spain
| | - Jonathan Hill
- King's College Hospital NHS Foundation Trust, London, UK.,Royal Brompton Hospital, London, UK
| | - Javier Escaned
- Hospital Clinico San Carlos Instituto Cardiovascular, Madrid, Comunidad de Madrid, Spain
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3
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Leick J, Werner N, Mangner N, Panoulas V, Aurigemma C. Optimized patient selection in high-risk protected percutaneous coronary intervention. Eur Heart J Suppl 2022; 24:J4-J10. [PMCID: PMC9730792 DOI: 10.1093/eurheartjsupp/suac060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Percutaneous mechanical circulatory support (pMCS) is increasingly used in patients with poor left-ventricular (LV) function undergoing elective high-risk percutaneous coronary interventions (HR-PCIs). These patients are often in critical condition and not suitable candidates for coronary artery bypass graft surgery. For the definition of HR-PCI, there is a growing consensus that multiple factors must be considered to define the complexity of PCI. These include haemodynamic status, left-ventricular ejection fraction, clinical characteristics, and concomitant diseases, as well as the complexity of the coronary anatomy/lesions. Although haemodynamic support by percutaneous LV assist devices is commonly adopted in HR-PCI (protected PCI), there are no clear guideline recommendations for indication due to limited published data. Therefore, decisions to use a nonsurgical, minimally invasive procedure in HR-PCI patients should be based on a risk–benefit assessment by a multidisciplinary team. Here, the current evidence and indications for protected PCI will be discussed.
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Affiliation(s)
- Jürgen Leick
- Department of Cardiology, Heart Centre Trier, Barmherzige Brüder Hospital , Nordallee 1, 54296 Trier , Germany
| | - Nikos Werner
- Department of Cardiology, Heart Centre Trier, Barmherzige Brüder Hospital , Nordallee 1, 54296 Trier , Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden , Dresden , Germany
| | - Vasileios Panoulas
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Harefield Hospital , London, Harefield, UB9 6BJ , UK
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London , UK
| | - Cristina Aurigemma
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome , Italy
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4
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Damluji AA, Tehrani B, Sinha SS, Samsky MD, Henry TD, Thiele H, West NEJ, Senatore FF, Truesdell AG, Dangas GD, Smilowitz NR, Amin AP, deVore AD, Moazami N, Cigarroa JE, Rao SV, Krucoff MW, Morrow DA, Gilchrist IC. Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:2003-2019. [PMID: 36265932 PMCID: PMC10312149 DOI: 10.1016/j.jcin.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 01/09/2023]
Abstract
In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Behnam Tehrani
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Marc D Samsky
- New York University School of Medicine, New York, New York, USA
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, Christ Hospital, Cincinnati, Ohio, USA
| | - Holger Thiele
- Heart Center Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | - Fortunato F Senatore
- Division of Cardiology and Nephrology, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Alexander G Truesdell
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - George D Dangas
- Division of Cardiology, Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | | | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Adam D deVore
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nader Moazami
- New York University School of Medicine, New York, New York, USA
| | | | - Sunil V Rao
- New York University School of Medicine, New York, New York, USA
| | | | - David A Morrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey Medical Center, Hershey, Pennsylvania, USA
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5
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Tayal R, Kalra S, Seth A, Chandra P, Sohal S, Punamiya K, Rao R, Rastogi V, Kapardhi PLN, Sharma S, Kumar P, Arneja J, Mathew R, Kumar D, Mahesh NK, Trehan V. Clinical expert consensus document on the use of percutaneous left ventricular assist devices during complex high-risk PCI in India using a standardised algorithm. ASIAINTERVENTION 2022; 8:75-85. [PMID: 36483283 PMCID: PMC9706744 DOI: 10.4244/aij-d-22-00021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/12/2022] [Indexed: 06/17/2023]
Abstract
Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.
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Affiliation(s)
- Rajiv Tayal
- Interventional Cardiology Unit, The Valley Hospital, Ridgewood, NJ, USA
| | - Sanjog Kalra
- Interventional Cardiology Unit, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Ashok Seth
- Interventional Cardiology Unit, Fortis Escorts Heart Institute, New Delhi, India
| | - Praveen Chandra
- Interventional Cardiology Unit, Medanta Heart Institute, Gurgaon, India
| | - Sumit Sohal
- Interventional Cardiology Unit, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Kirti Punamiya
- Interventional Cardiology Unit, Breach Candy Hospital, Mumbai, India
| | - Ravinder Rao
- Interventional Cardiology Unit, Rajasthan Hospital, Jaipur, India
| | - Vishal Rastogi
- Interventional Cardiology Unit, Fortis Escorts Heart Institute, New Delhi, India
| | - P L N Kapardhi
- Interventional Cardiology Unit, CARE Hospitals, Hyderabad, India
| | - Sanjeev Sharma
- Interventional Cardiology Unit, Eternal Hospital, Jaipur, India
| | - Prathap Kumar
- Interventional Cardiology Unit, Meditrina Group of Hospitals, Kollam, India
| | - Jaspal Arneja
- Interventional Cardiology Unit, Arneja Heart and Multispeciality Hospital, Nagpur, India
| | - Rony Mathew
- Interventional Cardiology Unit, Lisie Hospital, Ernakulam, India
| | - Dilip Kumar
- Interventional Cardiology Unit, Medica Superspecialty Hospital, Kolkata, India
| | - N K Mahesh
- Interventional Cardiology Unit, Apollo Adlux Hospital, Kochi, India
| | - Vijay Trehan
- Interventional Cardiology Unit, Govind Ballabh Pant Hospital, New Delhi, India
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6
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Power DA, Claessen B, Sharma SK. High Risk Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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7
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Jabbar A, Jbara Y, Ebrahimi A, Mufti O, Ali O, Markert R, Joffe D, Fishbein G. Left ventricular support for unprotected left main coronary artery interventions (the dayton heart and vascular impella registry). Heart Views 2022; 23:150-156. [DOI: 10.4103/heartviews.heartviews_6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/13/2022] [Indexed: 11/05/2022] Open
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8
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Brandão M, Caeiro D, Pires-Morais G, Almeida JG, Teixeira PG, Silva MP, Ponte M, Dias A, Oliveira M, Rodrigues A, Braga P. Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience. Rev Port Cardiol 2021; 40:853-861. [PMID: 34857158 DOI: 10.1016/j.repce.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES The use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings. METHODS We performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed. RESULTS Twenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group. CONCLUSION The short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates.
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Affiliation(s)
- Mariana Brandão
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal.
| | - Daniel Caeiro
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
| | | | | | | | | | - Marta Ponte
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
| | - Adelaide Dias
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
| | - Marco Oliveira
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
| | - Alberto Rodrigues
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
| | - Pedro Braga
- Cardiology Department, Centro Hospitalar Vila Nova de Gaia, Porto, Portugal
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9
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Disney L, Ramaiah C, Ramaiah M, Keshavamurthy S. Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting? Int J Angiol 2021; 30:194-201. [PMID: 34776819 DOI: 10.1055/s-0041-1730446] [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: 10/20/2022] Open
Abstract
The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.
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Affiliation(s)
- Logan Disney
- University of Kentucky College of Medicine, Lexington, Kentucky
| | | | | | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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10
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Brandão M, Caeiro D, Pires-Morais G, Almeida JG, Teixeira PG, Silva MP, Ponte M, Dias A, Oliveira M, Rodrigues A, Braga P. Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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11
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Zaiser AS, Fahrni G, Hollinger A, Knobel DT, Bovey Y, Zellweger NM, Buser A, Santer D, Pargger H, Gebhard CE, Siegemund M. Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices-A Retrospective, Single-Centre Cohort Study. J Clin Med 2021; 10:jcm10163710. [PMID: 34442010 PMCID: PMC8396891 DOI: 10.3390/jcm10163710] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/08/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
Worldwide, the left ventricular assist device Impella® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with its use. All patients treated with a left-sided Impella® device at the University Hospital of Basel from 1 January 2011 to 31 December 2019 were enrolled. The primary endpoint was the composite rate of mortality and adverse events (bleeding, acute kidney injury, and limb ischemia). Out of 281 included patients, at least one adverse event was present in 262 patients (93%). Rates of in-hospital, 90-day, and one-year mortality were 48%, 47%, and 50%, respectively. BARC type 3 bleeding (62%) and hemolysis (41.6%) were the most common complications. AKI was observed in 50% of all patients. Renal replacement therapy was required in 97 (35%) of all patients. Limb ischemia occurred in 13% of cases. Bleeding and hemolysis are common Impella®-associated complications. Additionally, we found a high rate of AKI. A careful selection of patients receiving microaxial LV support and defining the indication for its use are essential measures to be taken for the benefits to outweigh potential complications.
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Affiliation(s)
- Anna S. Zaiser
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Gregor Fahrni
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Demian T. Knobel
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Yann Bovey
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Núria M. Zellweger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Andreas Buser
- Regional Blood Transfusion Center SRK Basel and Department of Hematology, Transfusion Medicine, University Hospital Basel, 4031 Basel, Switzerland;
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland;
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Caroline E. Gebhard
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Correspondence: ; Tel.: +41-61-328-53-85
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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Sganzerla P, Cinelli F, Capoferri A, Rondi M. Left brachial artery: one more way to percutaneous insertion of IMPELLA 2.5L circulatory support for high-risk percutaneous coronary intervention - a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 4:1-5. [PMID: 33447709 PMCID: PMC7793212 DOI: 10.1093/ehjcr/ytaa281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/05/2020] [Accepted: 07/24/2020] [Indexed: 11/14/2022]
Abstract
Background Percutaneous circulatory support allows the performance of coronary interventions in ever more complex anatomic and clinical situations. The large-bore systems currently available need a suitable vascular calibre to be inserted restricting percutaneous access mainly to the common femoral artery. Case summary We present the case of a 64-year-old man, admitted with an acute coronary syndrome and congestive heart failure, due to triple-vessel coronary artery disease with left main involvement and left ventricular dysfunction. He was successfully treated with percutaneous coronary intervention (PCI) supported through an IMPELLA 2.5L circulatory system. Concomitant severe and diffuse peripheral vascular disease did not allow femoral insertion of the circulatory support which was therefore successfully introduced through a left brachial percutaneous approach. Discussion To the best of our knowledge, this is the first report of a brachial, percutaneous placement of the IMPELLA 2.5L system to support a high-risk PCI procedure. In appropriately selected patients, this approach could be an option when common vascular accesses are not available.
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Affiliation(s)
- Paolo Sganzerla
- Division of Cardiology, Department of Medical Sciences, ASST Bergamo Ovest, Ospedale di Treviglio, Treviglio, Bergamo, Italy
| | - Francesco Cinelli
- Division of Cardiology, Department of Medical Sciences, ASST Bergamo Ovest, Ospedale di Treviglio, Treviglio, Bergamo, Italy
| | - Andrea Capoferri
- Division of Cardiology, Department of Medical Sciences, ASST Bergamo Ovest, Ospedale di Treviglio, Treviglio, Bergamo, Italy
| | - Mauro Rondi
- Division of Cardiology, Department of Medical Sciences, ASST Bergamo Ovest, Ospedale di Treviglio, Treviglio, Bergamo, Italy
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13
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Chandrasekar B. Mechanical circulatory support with Impella in percutaneous coronary intervention: current status. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 1:100002. [PMID: 38560363 PMCID: PMC10976289 DOI: 10.1016/j.ahjo.2020.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 04/04/2024]
Abstract
In patients with, or at risk of, hemodynamic instability during percutaneous coronary intervention, maintaining perfusion of vital organs is crucial. The intra-aortic balloon pump and Impella are the two most commonly used percutaneous mechanical circulatory support devices. Intra-aortic balloon pump has been in widespread use for over three decades. Mechanical circulatory support with Impella is being used increasingly often in patients with acute myocardial infarction complicated by cardiogenic shock, and in those undergoing high-risk percutaneous coronary intervention. Besides improving cardiac output and coronary perfusion, Impella has potential myocardial protective effects. Three key measures that determine the clinical utility of a device are clinical outcome, device-related complications, and cost impact. In this review, the current data on use of Impella in patients with acute myocardial infarction complicated by cardiogenic shock, in left ventricular unloading in acute myocardial infarction, and in those undergoing high-risk percutaneous coronary intervention is analyzed.
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14
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Diaz Quintero L, Gajo E, Guerrero M, Feldman T, Levisay J. Balloon Aortic Valvuloplasty Followed by Impella®-Assisted Left Main Coronary Artery Percutaneous Coronary Intervention in Patients With Severe Aortic Stenosis as a Bridge to Transcatheter Aortic Valve Replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:16-21. [PMID: 32532627 DOI: 10.1016/j.carrev.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of Impella® to provide hemodynamic support during unprotected left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has been shown to be feasible, but severe AS is a relative contraindication for its use. Balloon aortic valvuloplasty (BAV) may facilitate the use of Impella® in these patients. OBJECTIVE To assess the feasibility of BAV followed by Impella®-assisted LMCA PCI in patients with severe AS as bridge to TAVR. METHODS Patients with symptomatic severe AS with LMCA stenosis ≥70% requiring PCI prior to TAVR were included. Outcomes were retrospectively collected. RESULTS Seven patients underwent BAV followed by Impella®-assisted LMCA PCI. Five patients were male; mean age 86 (75-91; SD ± 5.5). Mean STS score was 6.5% (4.3-13.8; SD ± 3.4). Impella® 2.5 L was used in all cases. The procedure was successful in all patients without peri-procedure complications. At 30-day post-BAV/PCI follow up, all patients had experienced improvement in NYHA class (N = 2 NYHA IV to III, N = 5 NYHA III to II). At such interval, mean EF was 54% (30-77; SD ± 17.7). The post BAV change in AVA [0.8 cm2 (0.4-1.5; SD ± 0.3; P = 0.07)], and AV mean gradient [30.8 mmHg (21-45; SD ± 8.9; P = 0.95)] after the procedure were not statistically significant. All patients underwent TAVR after a median PCI-to-TAVR interval of 62 days (33-339; SD ± 96.7). CONCLUSIONS BAV followed by Impella®-assisted LMCA PCI appears to be a feasible strategy for intermediate and high surgical risk patients with severe AS undergoing LMCA PCI as bridge to TAVR.
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Affiliation(s)
- Luis Diaz Quintero
- Department of Medicine, Abraham Lincoln Memorial Hospital, 200 Stahlhut Drive, Lincoln, IL 62656, USA.
| | - Eileen Gajo
- Department of Cardiology, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, 200 1(st) Street SW, Rochester, MN, USA, 55905
| | - Ted Feldman
- Edwards Lifesciences, 1 Edwards Way, Irvine, CA 92614, USA
| | - Justin Levisay
- Department of Medicine, Division of Cardiology, NorthShore University HealthSystem, 9650 Gross Point Road, Skokie, IL 60076, USA
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Panoulas V, Monteagudo-Vela M, Kalogeras K, Simon A. Subclavian Impella 5.0 to the rescue in a non-ST elevation myocardial infarction patient requiring unprotected left main rotablation: A case report. World J Cardiol 2020; 12:155-160. [PMID: 32431786 PMCID: PMC7215966 DOI: 10.4330/wjc.v12.i4.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Often in patients with significant three-vessel or left main disease there is coexistent significant peripheral disease rendering them poor candidates for percutaneous left ventricular support during revascularization. Evidence on the management of such cases is limited.
CASE SUMMARY We describe a case of such a patient with critical distal left main disease and chronically occluded right coronary artery who presented with chest pain and a non-ST elevation myocardial infarction and had significantly impaired left ventricular function. With the aid of our cardiothoracic surgeons a cut down subclavian Impella 5.0 was inserted and high risk rotablation percutaneous coronary intervention carried out successfully.
CONCLUSION This case highlights the need for cross-specialty collaborations in such high-risk cases were alternative access is needed for insertion of large bore mechanical circulatory support devices.
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Affiliation(s)
- Vasileios Panoulas
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London UB9 6JH, United Kingdom
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College, London SW7 2BU, United Kingdom
| | - María Monteagudo-Vela
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London UB9 6JH, United Kingdom
| | - Konstantinos Kalogeras
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London UB9 6JH, United Kingdom
| | - Andre Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London UB9 6JH, United Kingdom
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16
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Giblett JP. Does Impella Support Really Prevent Catastrophe? JACC Case Rep 2020; 2:668-669. [PMID: 34317318 PMCID: PMC8298659 DOI: 10.1016/j.jaccas.2020.01.025] [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: 11/17/2022]
Affiliation(s)
- Joel P. Giblett
- Division of Cardiology, Royal Jubilee Hospital, Victoria, British Columbia, Canada
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17
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Peigh G, Jivan A, Kosova E, Opyt A, Schimmel D, Ricciardi MJ. High Risk Coronary Atherectomy, Perforation, and Successful Percutaneous Treatment. JACC Case Rep 2020; 2:664-667. [PMID: 34317317 PMCID: PMC8298647 DOI: 10.1016/j.jaccas.2019.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/03/2019] [Indexed: 11/25/2022]
Abstract
We report a case of coronary perforation during high-risk percutaneous coronary intervention with Impella (Abiomed, Danvers, Massachusetts) support that resulted in cessation of pulsatile arterial flow. Maintenance of systemic perfusion due to antecedent placement of Impella 2.5 allowed for successful treatment with pericardiocentesis and covered stent placement, early discharge, and complication-free follow-up. (Level of Difficulty: Intermediate.)
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18
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Al-Rashid F, Mahabadi AA, Johannsen L, Soldat J, Dykun I, Jánosi RA, Totzeck M, Rassaf T. Impact of left-ventricular end-diastolic pressure as a predictor of periprocedural hemodynamic deterioration in patients undergoing Impella supported high-risk percutaneous coronary interventions. IJC HEART & VASCULATURE 2020; 26:100445. [PMID: 31799370 PMCID: PMC6881640 DOI: 10.1016/j.ijcha.2019.100445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND An increasing number of high-risk percutaneous coronary interventions (PCI) are performed with mechanical circulatory support (MCS) to minimize the risk of periprocedural hemodynamic compromise. Prior studies have demonstrated that an elevated left-ventricular end-diastolic pressure (LVEDP) is associated with worse outcome after acute myocardial infarction or cardiac surgery. Although LVEDP is frequently measured, little is known about the usefulness for predicting periprocedural hemodynamic deterioration in high-risk PCI. The objective of this study is to assess the impact of preprocedural measured LVEDP in non-shock patients undergoing high-risk PCI with MCS on periprocedural hemodynamic deterioration. METHODS AND RESULTS We reviewed the PCI protocol and the Automated Impella Controller in a consecutive series of 64 patients (mean age 73 years, 80% male), who underwent high-risk PCI with Impella MCS (period 01/2017-12/2018). LVEDP (17 ± 8 mm Hg) was measured in all cases before Impella insertion and start of PCI. Periprocedural hemodynamic deterioration was defined as: systolic blood pressure (SBP) drop (decrease ≥20 mm Hg or ≤90 mm Hg), or transient loss of arterial pressure pulsatility. Hemodynamic deterioration occurred in 33% (n = 21) of all patients but did not lead to a hemodynamic compromise due to the Impella support. Regression analysis of LVEDP for periprocedural hemodynamic deterioration or in-hospital major adverse cardiac and cerebrovascular events (MACCE) showed no significant results. CONCLUSION LVEDP was not associated with periprocedural hemodynamic deterioration or a higher rate of in-hospital MACCE. Our data propose that LVEDP may not be used as a risk stratification variable for MCS usage in non-shock patients undergoing high-risk PCI.
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Affiliation(s)
- Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, of the West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
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19
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Al-Rashid F, Totzeck M, Mahabadi AA, Johannsen L, Luedike P, Lind A, Krueger A, Kamler M, Kahlert P, Jánosi RA, Heusch G, Rassaf T. Safety and efficacy of a novel algorithm to guide decision-making in high-risk interventional coronary procedures. Int J Cardiol 2020; 299:87-92. [PMID: 31378378 DOI: 10.1016/j.ijcard.2019.07.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with severe coronary artery disease (CAD), comorbidities, or impaired hemodynamics are at risk during percutaneous coronary interventions. The aim of the study was to investigate the safety and efficacy of a novel risk-stratification algorithm for high-risk coronary procedures. METHODS AND RESULTS We prospectively screened 1189 patients with CAD requiring revascularization (period 07/2017-06/2018). The algorithm was designed to select high-risk procedures. Patients with elevated risk (n = 150) were classified into 3 risk groups (high-risk intervention [HRI] I-III) and procedural management was adjusted according to HRI group. Overall, 55 patients were categorized as HRI I, 52 as HRI II, and 43 as HRI III. With increasing HRI-level, SYNTAX score increased (HRI I:15 ± 5% vs. HRI II:24 ± 8% vs. HRI III:34 ± 7%; p < 0.001), and ejection-fraction decreased (HRI I:48 ± 10% vs. HRI II:49 ± 10% vs. HRI III:40 ± 11%; p < 0.001). The primary endpoint (hemodynamic compromise requiring mechanical circulatory support [MCS] [HRI I/II], unsuccessful weaning from MCS in the catheterization laboratory[HRI III], or periprocedural death[HRI I-III]) occurred in no case. The secondary endpoint of hemodynamic deterioration occurred in 26% (n = 39) but did not result in hemodynamic instability due to the risk-adjusted procedural management. The composite endpoint of in-hospital major adverse cardiac and cerebrovascular events (death, new myocardial infarction, cerebrovascular accident) occurred in 4 patients (3%). CONCLUSIONS The novel algorithm is a safe team-based stratification method for the identification and management of patients undergoing high-risk coronary interventions.
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Affiliation(s)
- Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Laura Johannsen
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Alexander Lind
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Andrea Krueger
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-, Essen, Germany
| | - Philipp Kahlert
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Germany.
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20
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Chopra AM, Rapkiewicz A, Daggubati R, Sequeira A, Hu YC, Bhatt DL, Sharma SK, Cruz JP, Tzafriri AR, Edelman ER. Analysis: Intravascular Devices with a Higher Risk of Polymer Emboli: The Need for Particulate Generation Testing. Biomed Instrum Technol 2020; 54:37-43. [PMID: 31961742 PMCID: PMC10520951 DOI: 10.2345/0899-8205-54.1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Hydrophilic polymer coatings on intravascular devices lower friction between the device and vasculature, thereby reducing trauma during interventional procedures. Polymer coating embolism-the detachment and downstream embolism of polymer particles-has been reported as an iatrogenic complication of coated interventional devices affecting the vasculature and various organs. The Food and Drug Administration (FDA) acknowledges this complication and continues to work with stakeholders to close gaps in performance testing and standards related to polymer coating integrity. Recent innovations within interventional technologies have led to development of new hydrophilic-coated devices with expanded indications for use. The 2018 FDA draft guidance for intravascular guidewires expands the application of particulate generation testing to most devices and recommends labeling changes to increase industry awareness. This article highlights current procedural trends where the phenomenon of polymer coating embolism may be more prevalent. It describes the mechanisms of polymer separation, reported clinical sequelae, and risk factors for relevant indications. These procedural trends and associated risk factors articulate the need for particulate testing and support the FDA's draft guidance recommendations for performance testing of applied coatings. If standardized, particulate assessments may allow characterization and comparisons of coating integrity among devices from various manufacturers, and are an important foundation for setting particulate limits. As hydrophilic coatings enable endovascular treatment for a range of patient populations, setting particulate limits or finding alternative solutions without compromise to device function may be essential. Particulate testing is relevant to physicians, regulators, and manufacturers for the purposes of product development and quality improvement of interventional devices.
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21
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Johannsen L, Mahabadi AA, Totzeck M, Krueger A, Jánosi RA, Rassaf T, Al-Rashid F. Access site complications following Impella-supported high-risk percutaneous coronary interventions. Sci Rep 2019; 9:17844. [PMID: 31780769 PMCID: PMC6882834 DOI: 10.1038/s41598-019-54277-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/09/2019] [Indexed: 01/22/2023] Open
Abstract
Mechanical circulatory support (MCS) devices are increasingly used to provide hemodynamic stability for patients with severe coronary artery disease, comorbidities, and/or impaired hemodynamics during high-risk percutaneous coronary interventions (PCI). Vascular access site complications, particularly those due to the use of large-bore sheaths, may limit outcomes in these patients. The aim of this study was to investigate the incidence and predictors of vascular complications in protected high-risk PCIs. Therefore, we included patients undergoing high-risk PCI with an Impella device from January 2016 to August 2018. Vascular complications were graded according to 'Valve Academic Research Consortium-2', a definition routinely used in transcatheter valve implantation procedures. In total, 61 patients (mean age 72 ± 11 years, 79% male, SYNTAX score 33 ± 7) were included, and angiographic- and fluoroscopic-guided vascular access was used for Impella implantation in all patients. Major vascular complications occurred in 5 male patients (8%). All major vascular complications were treated conservatively without the need for surgical intervention, and only one patient received a transfusion of three erythrocyte concentrates. Regression analysis revealed that patients with peripheral arterial disease of the lower extremities are at higher risk of major vascular complications. In conclusion, the utilization of Impella using a standardized protocol for angiographic- and fluoroscopic-guided vascular access was associated with a low rate of vascular complications.
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Affiliation(s)
- Laura Johannsen
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Andrea Krueger
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany.
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22
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Nonemergent Percutaneous Coronary Intervention on an Unprotected Left Main Coronary Artery Supported with Impella® Heart Pump in Patients Ineligible for Surgical Revascularization. J Interv Cardiol 2019; 2019:9691753. [PMID: 31772553 PMCID: PMC6739763 DOI: 10.1155/2019/9691753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 03/07/2019] [Indexed: 01/22/2023] Open
Abstract
Objectives We sought to assess if ineligibility to coronary artery bypass grafting (CABG) constitutes a risk factor in patients who underwent a nonemergent unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with prophylactic Impella® heart pump support. Background ULMCA PCI in patients not deemed eligible for CABG is associated with significantly worse outcomes compared to ULMCA PCI in eligible patients. Methods Patients from the cVAD Registry and the PROTECT II trial who underwent a nonemergent ULMCA PCI were identified. We compared in-hospital mortality and major adverse cardiac and cerebrovascular event (MACCE) rates as well as 30-day survival and MACCE rates between CABG ineligible and CABG eligible patients. Results A total of 331 patients were included (293 Impella 2.5®, 38 Impella CP®); 227 were ineligible for CABG and 104 were eligible. Baseline characteristics were remarkable for a trend toward higher rate of chronic obstructive pulmonary disease in the ineligible patients. In-hospital mortality (3.52% vs. 5.77%; p=0.383) and MACCE (6.61% vs. 7.69%; p=0.816) rates as well as 30-day survival (92.0% vs. 93.4%; Log-Rank p-value =0.781) and MACCE (88.1% vs. 90.1%; Log-Rank p-value=0.648) rates were not different between the two groups. Conclusions The results of our study suggest that prophylactic Impella support appears to mitigate the risks inherent to surgical ineligibility in patients undergoing a nonemergent ULMCA PCI. Our results require further investigation.
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23
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Risk of contrast-induced nephropathy in patients undergoing complex percutaneous coronary intervention. Int J Cardiol 2019; 290:59-63. [DOI: 10.1016/j.ijcard.2019.04.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/07/2019] [Accepted: 04/12/2019] [Indexed: 01/06/2023]
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Lazicki TJ, Pagel PS. Reduced Flow Rate, Acute Hemolysis, and Restricted Anterior Mitral Leaflet Opening During Mechanical Circulatory Support for End-stage Nonischemic Cardiomyopathy. J Cardiothorac Vasc Anesth 2019; 34:562-565. [PMID: 31399307 DOI: 10.1053/j.jvca.2019.07.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Timothy J Lazicki
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
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25
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Chieffo A, Burzotta F, Pappalardo F, Briguori C, Garbo R, Masiero G, Nicolini E, Ribichini F, Trani C, Álvarez BC, Leor OR, Moreno R, Santos R, Fiarresga A, Silveira JB, de Prado AP, Musumeci G, Esposito G, Tarantini G. Clinical expert consensus document on the use of percutaneous left ventricular assist support devices during complex high-risk indicated PCI: Italian Society of Interventional Cardiology Working Group Endorsed by Spanish and Portuguese Interventional Cardiology Societies. Int J Cardiol 2019; 293:84-90. [PMID: 31174920 DOI: 10.1016/j.ijcard.2019.05.065] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/18/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022]
Abstract
Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Vita Salute University, Milan, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | | | - Giulia Masiero
- Cardiovascular Department, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Elisa Nicolini
- Unità di Emodinamica, Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Carlo Trani
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Raúl Moreno
- Hospital Universitario La Paz, IDIPAZ, Madrid, Spain
| | | | - António Fiarresga
- Centro Hospitalar Lisboa Central, Hospital de Santa Marta, Lisboa, Portugal
| | - João Brum Silveira
- Centro Hospitalar e Universitário do Porto, Hospital de Santo António, Porto, Portugal
| | | | - Giuseppe Musumeci
- Cardiovascular Department, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Divisions of Cardiology and Cardiothoracic Surgery, Federico II University, Naples, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, University of Padova, Italy..
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Burzotta F, Russo G, Ribichini F, Piccoli A, D'Amario D, Paraggio L, Previ L, Pesarini G, Porto I, Leone AM, Niccoli G, Aurigemma C, Verdirosi D, Crea F, Trani C. Long-Term Outcomes of Extent of Revascularization in Complex High Risk and Indicated Patients Undergoing Impella-Protected Percutaneous Coronary Intervention: Report from the Roma-Verona Registry. J Interv Cardiol 2019; 2019:5243913. [PMID: 31772533 PMCID: PMC6739781 DOI: 10.1155/2019/5243913] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To investigate the effect of extent of revascularization in complex high-risk indicated patients (CHIP) undergoing Impella-protected percutaneous coronary intervention (PCI). BACKGROUND Complete revascularization has been shown to be associated with improved outcomes. However, the impact of more complete revascularization during Impella-protected PCI in CHIP has not been reported. METHODS A total of 86 CHIP undergoing elective PCI with Impella 2.5 or Impella CP between April 2007 and December 2016 from 2 high volume Italian centers were included. Baseline, procedural, and clinical outcomes data were collected retrospectively. Completeness of coronary revascularization was assessed using the British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) derived revascularization index (RI). The primary end-point was all-cause mortality. A multivariate regression model was used to identify independent predictors of mortality. RESULTS All patients had multivessel disease and were considered unsuitable for surgery. At baseline, 44% had left main disease, 78% had LVEF ≤ 35%, and mean BCIS-JS score was 10±2. The mean BCIS-JS derived RI was 0.7±0.2 and procedural complications were uncommon. At 14-month follow-up, all-cause mortality was 10.5%. At follow-up, 67.4% of CHIP had LVEF ≥ 35% compared to 22.1% before Impella protected-PCI. Higher BCIS-JS RI was significantly associated with LVEF improvement (p=0.002). BCIS-JS RI of ≤ 0.8 (HR 0.11, 95% CI 0.01- 0.92, and p = 0.042) was an independent predictor of mortality. CONCLUSIONS These results support the practice of percutaneous Impella use for protected PCI in CHIP. A more complete revascularization was associated with significant LVEF improvement and survival.
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Affiliation(s)
- Francesco Burzotta
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giulio Russo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Anna Piccoli
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Domenico D'Amario
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lazzaro Paraggio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Leonardo Previ
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Italo Porto
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Maria Leone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giampaolo Niccoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Cristina Aurigemma
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Diana Verdirosi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Carlo Trani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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Konstantinou K, Keeble TR, Kelly PA, Alsanjari O, Napp LC, Karamasis GV, Davies JR. Protected percutaneous coronary intervention with Impella CP in a patient with left main disease, severe left ventricular systolic dysfunction and established hemolysis. Cardiovasc Diagn Ther 2019; 9:194-199. [PMID: 31143642 DOI: 10.21037/cdt.2019.02.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The use of the Impella device in patients with left ventricular (LV) systolic impairment undergoing left main (LM) percutaneous coronary intervention (PCI) has been growing exponentially. Data from observational studies and registries demonstrate that Impella-assisted high-risk PCI is safe and effective with a low rate of peri-procedural complications. Hemolysis is a potential limitation of virtually all mechanical circulatory support devices and a small incidence of hemolysis has been associated with Impella use. The safety and feasibility of Impella use in patients with established hemolysis has not been previously evaluated. We report the first described case in the literature of Impella-assisted left main stem (LMS) PCI in a patient with severe LV systolic dysfunction and autoimmune hemolytic anemia (AIHA). Despite the patient's high bleeding risk (active hemolysis, thrombocytopenia, impaired renal function, use of steroids), Impella placement and PCI were successfully performed without complication. Haemoglobin, bilirubin and lactate dehydrogenase (LDH) levels were closely monitored peri-procedurally with no evidence of exacerbation of the patient's hemolysis. We briefly discuss the mechanism of Impella-induced hemolysis and factors that can exacerbate hemolysis.
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Affiliation(s)
- Klio Konstantinou
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK.,Anglia Ruskin University School of Medicine, Faculty of Medical Science, Chelmsford, UK
| | - Thomas R Keeble
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK.,Anglia Ruskin University School of Medicine, Faculty of Medical Science, Chelmsford, UK
| | - Paul A Kelly
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Osama Alsanjari
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK.,Anglia Ruskin University School of Medicine, Faculty of Medical Science, Chelmsford, UK
| | - L Christian Napp
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Grigoris V Karamasis
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK.,Anglia Ruskin University School of Medicine, Faculty of Medical Science, Chelmsford, UK
| | - John R Davies
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals, Basildon, UK.,Anglia Ruskin University School of Medicine, Faculty of Medical Science, Chelmsford, UK
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Aggarwal B, Aman W, Jeroudi O, Kleiman NS. Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention. Methodist Debakey Cardiovasc J 2018; 14:23-31. [PMID: 29623169 DOI: 10.14797/mdcj-14-1-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Due to advancing age and increasing comorbidities, the current population has a higher incidence of complex coronary artery disease, often without surgical options for revascularization. In this setting, hemodynamic support devices are an important adjunct in the interventionist's toolbox as they allow for a safer, more effective procedure. The following paper reviews the indications of various available mechanical support devices, highlights their clinical data and technical parameters, and offers a practical approach towards appropriate patient and device selection.
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Affiliation(s)
- Bhuvnesh Aggarwal
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Wahaj Aman
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Omar Jeroudi
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Neal S Kleiman
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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Successful Treatment of Occlusive Left Main Coronary Artery Dissection by Impella-Supported Stenting. Case Rep Cardiol 2018; 2018:5373625. [PMID: 30116644 PMCID: PMC6079505 DOI: 10.1155/2018/5373625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/08/2018] [Indexed: 11/17/2022] Open
Abstract
We report successful treatment of a patient, who, during diagnostic angiography, developed an ostial left main coronary artery dissection with stump occlusion of the vessel. First, mechanical circulatory support with an Impella CP device was established. Then, patency of the left coronary system was achieved by placement of stents in the left anterior descending, left circumflex, and left main coronary arteries. On completion of the procedure, left ventricular systolic function, as assessed by echocardiography, was normal. At 24-month clinical follow-up, the patient remains angina-free and well. This is the first reported case of the use of an Impella device to support treatment of iatrogenic left main coronary artery dissection.
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30
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Left Main Disease: What Is the Correct Approach to Revascularization? Cardiol Rev 2018; 26:219-229. [PMID: 29794807 DOI: 10.1097/crd.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Percutaneous coronary intervention of the left main coronary artery has evolved through registries and meta analyses, supported by results from the EXCEL [Everolimus-Eluting Stents (EES) or Bypass Surgery for Left Main Coronary Artery Disease] and NOBLE (Percutaneous Coronary Angioplasty versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trials as an acceptable alternative to coronary artery bypass grafting in patients with low and intermediate Syntax scores. Advances in stenting strategies and the availability of larger diameter drug-eluting stents improve patient safety and optimize procedural and patient outcomes.
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The cVAD registry for percutaneous temporary hemodynamic support: A prospective registry of Impella mechanical circulatory support use in high-risk PCI, cardiogenic shock, and decompensated heart failure. Am Heart J 2018; 199:115-121. [PMID: 29754648 DOI: 10.1016/j.ahj.2017.09.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/10/2017] [Indexed: 01/17/2023]
Abstract
Management of patients requiring temporary, mechanical hemodynamic support during high- risk percutaneous coronary intervention (PCI) or in cardiogenic shock is rapidly evolving. With the availability of the Impella 2.5, CP, 5.0, LD, and RP percutaneous mechanical circulatory support devices, there is a need for continued surveillance of outcomes. Three factors underline the importance of a registry for these populations. First, large randomized trials of hemodynamic support, involving cardiogenic shock, are challenging to conduct. Second, there is increasing interest in the use of registries to provide "real-world" experience and to allow the flexibility to evaluate individual patient uses and outcomes. Third, current, large databases have not captured the specific impact of mechanical support treatment of cardiogenic shock. The predecessor to the catheter-based ventricular assist devices registry, known as USpella, began in 2009 with paper data acquisition but beginning in 2011 transferred to electronic data capture, enrolling 3,339 patients through 2016. Throughout, registry data have been used to assess the outcomes of Impella therapy, leading to 8 publications and 4 Food and Drug Administration premarket approvals covering multiple indications and Impella devices. Going forward, the registry will continue to assess not only in-hospital outcomes but long-term follow-up to 1 year. In addition, data management will be enhanced to assess quality and clinical experiences. The registry will also provide a mechanism for postmarketing surveillance. This manuscript reviews the ongoing catheter-based ventricular assist devices registry design, management, and contributions of the registry data. The upgraded registry will provide a more robust opportunity to assess acute and late outcomes of current and future device use worldwide. CONDENSED ABSTRACT The current catheter-based ventricular assist devices registry is an international database documenting outcomes with temporary Impella hemodynamic support. The registry has supported 8 publications and 4 Food and Drug Administration premarket approvals since its inception in 2009. The current registry is more robust containing outcomes up to 1 year postprocedure.
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Operator Experience and Outcomes After Left Main Percutaneous Coronary Intervention. Curr Cardiol Rep 2018; 20:29. [PMID: 29572751 DOI: 10.1007/s11886-018-0972-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW This review was performed with the goal of summarizing the role of operator experience in the treatment of severe left main stenosis by percutaneous intervention techniques. RECENT FINDINGS The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial demonstrated that percutaneous coronary intervention and coronary artery bypass grafting had similar clinical outcomes for severe left main disease. However, PCI of the left main coronary stenosis is considered to be a high-risk intervention because of the large area of myocardium at jeopardy that can quickly cause hemodynamic compromise. Operator experience and familiarity with the use of hemodynamic support devices, plaque modification techniques, and intravascular imaging tools is associated with better clinical outcomes. In patients with severe left main stenosis undergoing percutaneous coronary intervention by high-volume operators, the clinical outcomes are superior.
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Becher T, Baumann S, Eder F, Perschka S, Loßnitzer D, Fastner C, Behnes M, Doesch C, Borggrefe M, Akin I. Comparison of peri and post-procedural complications in patients undergoing revascularisation of coronary artery multivessel disease by coronary artery bypass grafting or protected percutaneous coronary intervention with the Impella 2.5 device. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:360-368. [PMID: 28660768 DOI: 10.1177/2048872617717687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND While coronary artery bypass grafting remains the standard treatment of complex multivessel coronary artery disease, the advent of peripheral ventricular assist devices has enhanced the safety of percutaneous coronary intervention. We therefore evaluated the safety in terms of inhospital outcome comparing protected high-risk percutaneous coronary intervention with the Impella 2.5 device and coronary artery bypass grafting in patients with complex multivessel coronary artery disease. METHODS This retrospective study included patients with complex multivessel coronary artery disease (SYNTAX score >22) undergoing either coronary artery bypass grafting before the implementation of a protected percutaneous coronary intervention programme with a peripheral ventricular assist device or protected percutaneous coronary intervention with the Impella 2.5 device following the start of the programme. The primary endpoint consisted of inhospital major adverse cardiac and cerebrovascular events. The combined secondary endpoint included peri and post-procedural adverse events. RESULTS A total of 54 patients (mean age 70.1±9.9 years, 92.6% men) were enrolled in the study with a mean SYNTAX score of 34.5±9.8. Twenty-six (48.1%) patients underwent protected percutaneous coronary intervention while 28 (51.9%) patients received coronary artery bypass grafting. The major adverse cardiac and cerebrovascular event rate was numerically higher in the coronary artery bypass grafting group (17.9 vs. 7.7%; P=0.43) but was not statistically significant. The combined secondary endpoint was not different between the groups; however, patients undergoing coronary artery bypass grafting experienced significantly more peri-procedural adverse events (28.6 vs. 3.8%; P<0.05). CONCLUSION Patients with complex multivessel coronary artery disease undergoing protected percutaneous coronary intervention with the Impella 2.5 device experience similar intrahospital major adverse cardiac and cerebrovascular event rates when compared to coronary artery bypass grafting. Protected percutaneous coronary intervention represents a safe alternative to coronary artery bypass grafting in terms of inhospital adverse events.
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Affiliation(s)
- Tobias Becher
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Stefan Baumann
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Frederik Eder
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany
| | - Simon Perschka
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany
| | - Dirk Loßnitzer
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Christian Fastner
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Michael Behnes
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Christina Doesch
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Martin Borggrefe
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
| | - Ibrahim Akin
- 1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Mannheim, Germany.,2 DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Germany
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