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Di Muro FM, Bellino M, Esposito L, Attisano T, Meucci F, Mattesini A, Galasso G, Vecchione C, Di Mario C. Role of Mechanical Circulatory Support in Complex High-Risk and Indicated Percutaneous Coronary Intervention: Current Indications, Device Options, and Potential Complications. J Clin Med 2024; 13:4931. [PMID: 39201073 PMCID: PMC11355104 DOI: 10.3390/jcm13164931] [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: 06/30/2024] [Revised: 08/13/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Improved expertise and technological advancements have enabled the safe and effective performance of complex and high-risk-indicated percutaneous coronary intervention (CHIP) in patients previously considered inoperable or high-risk. Mechanical circulatory support (MCS) devices play a crucial role in stabilizing hemodynamics during percutaneous coronary intervention (PCI) -related ischemia, thereby reducing the risk of major adverse events and achieving a more complete revascularization. However, the use of MCS devices in protected PCI is not without risks, including peri-procedural myocardial infarction (MI), bleeding, and access-related complications. Despite numerous observational studies, there is a significant lack of randomized clinical trials comparing different MCS devices in various CHIP scenarios and evaluating their long-term safety and efficacy profiles. This review aims to summarize the current evidence regarding the benefits of MCS devices during CHIPs, offer a practical guide for selecting appropriate devices based on clinical scenarios, and highlight the unanswered questions that future trials need to address.
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Affiliation(s)
- Francesca Maria Di Muro
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, Careggi University Hospital, University of Florence, 50134 Florence, Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Luca Esposito
- Department of Advanced Biomedical Sciences, University Federico II, 80138 Naples, Italy;
| | - Tiziana Attisano
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Francesco Meucci
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
| | - Alessio Mattesini
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
- Vascular Pathophysiology Unit, IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Carlo Di Mario
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
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2
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Karacsonyi J, Stanberry L, Simsek B, Kostantinis S, Allana SS, Rempakos A, Okeson B, Alaswad K, Basir MB, Jaffer F, Poommipanit P, Khatri J, Patel M, Mahmud E, Sheikh A, Wollmuth JR, Yeh RW, Chandwaney RH, ElGuindy AM, Abi Rafeh N, Schimmel DR, Benzuly K, Burke MN, Rangan BV, Mastrodemos OC, Sandoval Y, Ungi I, Brilakis ES. Development of a Novel Score to Predict Urgent Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2023; 202:111-118. [PMID: 37429059 DOI: 10.1016/j.amjcard.2023.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/12/2023]
Abstract
Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision-making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample and on 2,411 out-of-sample procedures that did not require urgent MCS. Urgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63 to 77] vs 66 [58 to 73] years, p = 0.003) compared with those who did not require urgent MCS. Technical (68% vs 87%, p <0.001) and procedural success (40% vs 85%, p <0.001) was lower in the urgent MCS group compared with cases that did not require urgent MCS. The risk model for urgent MCS use included retrograde crossing strategy, left ventricular ejection fraction, and lesion length. The resulting model demonstrated good calibration and discriminatory capacity with the area under the curve (95% confidence interval) of 0.79 (0.73 to 0.86) and specificity and sensitivity of 86% and 52%, respectively. In the out-of-sample set, the specificity of the model was 87%. The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI.
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Affiliation(s)
- Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa Stanberry
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Spyridon Kostantinis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Salman S Allana
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Athanasios Rempakos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Brynn Okeson
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Khaldoon Alaswad
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Mir B Basir
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Farouc Jaffer
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul Poommipanit
- Department of Cardiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Jaikirshan Khatri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mitul Patel
- Cardiovascular Institute, VA San Diego Healthcare System and University of California San Diego, La Jolla, California
| | - Ehtisham Mahmud
- Cardiovascular Institute, VA San Diego Healthcare System and University of California San Diego, La Jolla, California
| | - Abdul Sheikh
- Interventional Cardiology Department, WellStar Health System, Marietta, Georgia
| | - Jason R Wollmuth
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Raj H Chandwaney
- Interventional Cardiology, Oklahoma Heart Institute, Tulsa, Oklahoma
| | - Ahmed M ElGuindy
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Nidal Abi Rafeh
- Department of Cardiology, North Oaks Health System, Hammond, Louisiana
| | - Daniel R Schimmel
- Cardiovascular Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Keith Benzuly
- Cardiovascular Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - M Nicholas Burke
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Olga C Mastrodemos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Yader Sandoval
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Imre Ungi
- Division of Invasive Cardiology, Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.
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Al-Khadra Y, Salih M, Al-Akchar M, Sawalha K, DeMartini T, Hafiz AM. National Trends of Percutaneous Mechanical Support Utilization During Percutaneous Coronary Interventions in Chronic Total Occlusion. Am J Cardiol 2023; 200:215-222. [PMID: 37390576 DOI: 10.1016/j.amjcard.2023.05.029] [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] [Received: 02/26/2023] [Revised: 04/22/2023] [Accepted: 05/07/2023] [Indexed: 07/02/2023]
Abstract
Coronary chronic total occlusion (CTO) is common in patients with multivessel coronary artery disease. Percutaneous coronary artery (PCI) interventions have shown favorable outcomes in patients with CTO. Nevertheless, the data regarding the utilization of mechanical circulatory support in CTO PCIs is not well established. We sought to investigate the trends in utilization and periprocedural complications in this population. Using the National Inpatient Sample database from 2011 to 2019, we identified patients diagnosed with CTO who underwent PCI. We investigated the presence of a linear trend in the utilization of mechanical circulatory support (MCS) during those procedures and the associated periprocedural complications using the Cochran-Armitage method. A total of 208,123 patients who were diagnosed with CTO and underwent PCI from 2011 to 2019, of which in 6,319 patients MCS was used during the procedure. Patients in the MCS group were older (67.4 vs 66.4 years), less likely to be women (24.0% vs 26.4%), and equally likely to be African-American (9.4% vs 8.8%) with a higher burden of co-morbidities in terms of coronary artery disease, congestive heart failure, and atrial fibrillation (p <0.001 for all). Using the Cochrane-Armitage method, we found a statistically significant linear uptrend in the utilization of MCS from 269 (1.4%) to 990 cases (7.0%) from 2011 to 2019. Using multivariable logistic regression, female gender, renal failure, alcohol abuse, coagulopathy, and fluid and electrolyte disorders were identified as independent predictors of mortality in CTO PCI procedures assisted with MCS (p ≤0.007). In conclusion, the utilization of MCS in CTO PCI procedures has been increasing over the years. Female gender and renal failure are independently associated with a higher mortality risk.
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Affiliation(s)
- Yasser Al-Khadra
- Cardiovascular Division, Southern Illinois University School of Medicine, Springfield, Illinois.
| | - Mohsin Salih
- Cardiovascular Division, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Mohammad Al-Akchar
- Cardiovascular Division, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Khalid Sawalha
- Department of Internal Medicine, UMass Chan Medical School-Baystate campus, Springfield, Massachusetts
| | - Tony DeMartini
- Cardiovascular Division, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Abdul Moiz Hafiz
- Cardiovascular Division, Southern Illinois University School of Medicine, Springfield, Illinois
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4
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Khatri J. Mechanical Circulatory Support in High-Risk Coronary Intervention: Rational or Just Trendy? Am J Cardiol 2023:S0002-9149(23)00371-5. [PMID: 37385926 DOI: 10.1016/j.amjcard.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Jaikirshan Khatri
- Interventional Cardiology, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Karacsonyi J, Deffenbacher K, Benzuly KH, Flaherty JD, Alaswad K, Basir M, Megaly MS, Jaffer F, Doshi D, Poommipanit P, Khatri J, Patel M, Riley R, Sheikh A, Wollmuth JR, Korngold E, Uretsky BF, Yeh RW, Chandwaney RH, Elguindy AM, Tammam K, AbiRafeh N, Schmidt CW, Okeson B, Kostantinis S, Simsek B, Rangan BV, Brilakis ES, Schimmel DR. Use of Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2023; 189:76-85. [PMID: 36512989 DOI: 10.1016/j.amjcard.2022.10.049] [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] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022]
Abstract
The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p <0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p <0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p <0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p <0.001) and procedural (39% vs 86%, p <0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p <0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates.
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Affiliation(s)
- Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Karen Deffenbacher
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Keith H Benzuly
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James D Flaherty
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Khaldoon Alaswad
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Mir Basir
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Michael S Megaly
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Farouc Jaffer
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Darshan Doshi
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul Poommipanit
- Cardiac Catheterization Laboratory, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Mitul Patel
- Interventional Cardiology, VA San Diego Healthcare System and University of California San Diego, San Diego, California
| | - Robert Riley
- Cardiology, Overlake Medical Center, Bellevue, Washington
| | - Abdul Sheikh
- Cardiovascular Medicine, Wellstar Health System, Marietta, Georgia
| | - Jason R Wollmuth
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Ethan Korngold
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Barry F Uretsky
- Interventional Cardiology, Central Arkansas Veterans Healthcare System, and University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Robert W Yeh
- Medicine Department, Beth Israe, Deaconess Medical Center, Boston, Massachusetts
| | - Raj H Chandwaney
- Interventional Cardiology, Oklahoma Heart Institute, Tulsa, Oklahoma
| | - Ahmed M Elguindy
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Khalid Tammam
- Interventional Cardiology, International Medical Center, Jeddah, Saudi Arabia
| | - Nidal AbiRafeh
- Cardiology, North Oaks Health System, Hammond, Louisiana
| | - Christian W Schmidt
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Brynn Okeson
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Spyridon Kostantinis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Daniel R Schimmel
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Sengodan P, Davies RE, Matsuno S, Chan AK, Kearney K, Salisbury A, Grantham JA, Hirai T. Chronic Total Occlusion Interventions in Patients with Reduced Ejection Fraction. Curr Cardiol Rep 2023; 25:43-50. [PMID: 36576680 DOI: 10.1007/s11886-022-01832-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF THE REVIEW The goal of this paper is to review the current evidence surrounding CTO PCI in patients with low EF, the most high-risk population to treat. We also present pertinent case examples and offer practical tips to increase success and lower complications when performing CTO PCI in patients with low EF. RECENT FINDINGS In a prospective randomized control study, greater improvement in angina frequency and quality of life, assessed by the Seattle Angina Questionnaire, was achieved by CTO PCI compared to optimal medical therapy. Furthermore, after successful CTO PCI, improvements in health status were similar in patients with both low and normal EF. CTO PCI can not only ameliorate symptoms of angina in patients with low EF but may also potentially improve EF in carefully selected populations. However, information regarding treatment of this high-risk population is lacking and large-scale studies targeting patients with severely reduced EF remain necessary.
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Affiliation(s)
| | | | | | - Albert K Chan
- University of Missouri Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | | | - Adam Salisbury
- St. Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Taishi Hirai
- University of Missouri Columbia, One Hospital Drive, Columbia, MO, 65212, USA.
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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: 5] [Impact Index Per Article: 2.5] [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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Kobayashi N, Ito Y, Kishi K, Muramatsu T, Okada H, Oikawa Y, Kawasaki T, Yoshikawa R, Tanaka H, Katoh O. Procedural results and in-hospital outcomes of percutaneous coronary intervention for chronic total occlusion in patients with reduced left ventricular ejection fraction: Sub-analysis of the Japanese CTO-PCI Expert Registry. Catheter Cardiovasc Interv 2022; 100:30-39. [PMID: 35652164 DOI: 10.1002/ccd.30231] [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] [Received: 11/22/2021] [Revised: 04/06/2022] [Accepted: 05/03/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate the procedural results and in-hospital outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients with reduced left ventricular ejection fraction (LVEF). BACKGROUND While the technical success of general CTO-PCI has improved, CTO-PCI patients with reduced LVEF remain at high-risk for adverse events. METHODS The data of 820 patients with LVEF ≤ 35% (Group 1), 1816 patients with LVEF = 35%-50% (Group 2), and 5503 patients with LVEF ≥ 50% (Group 3), registered in the Japanese CTO-PCI Expert Registry from January 2014 to December 2019, were retrospectively analyzed. The primary endpoint was in-hospital major adverse cardiac or cerebrovascular events (MACCEs), including death, myocardial infarction, stent thrombosis, stroke, and emergent revascularization. Secondary endpoints included procedural details, guidewire success, and technical success. RESULTS There were no differences in guidewire and technical success rates between the groups. In-hospital MACCEs was significantly higher in Group 1 (Group 1 vs. Group 2 vs. Group 3: 3.4% vs. 1.7% vs. 1.5%, p = 0.001) and was especially driven by death (1.3% vs. 0.3% vs. 0.1%, p < 0.001) and stroke (0.7% vs. 0.2% vs. 0.2%, p = 0.007). Multivariate analysis showed that LVEF ≤ 35% (odds ratio [OR]; 1.58, 95% confidence interval [CI]; 1.04-2.41, p = 0.03) and New York Heart Association (NYHA) class ≥ 3 (OR; 2.01, 95% CI; 1.03-3.93, p = 0.04) were predictors of in-hospital MACCEs. CONCLUSIONS In-hospital MACCEs were significantly higher in patients with LVEF ≤ 35%. LVEF ≤;35% and NYHA class ≥ 3 were predictors of in-hospital MACCEs after CTO-PCI.
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Affiliation(s)
- Norihiro Kobayashi
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Yoshiaki Ito
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Koichi Kishi
- Department of Cardiology, Tokushima Red Cross Hospital, Komatsushima, Japan
| | - Toshiya Muramatsu
- Department of Cardiology, Tokyo Heart Center, Shinagawa-ku, Japan, Tokyo
| | - Hisayuki Okada
- Department of Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, the Cardiovascular Institute, Tokyo, Japan
| | | | | | - Hiroyuki Tanaka
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Osamu Katoh
- Japanese CTO-PCI Expert Foundation, Kurashiki, Japan
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9
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Muraca I, Carrabba N, Virgili G, Bruscoli F, Migliorini A, Pennesi M, Pontecorboli G, Marchionni N, Valenti R. Chronic total occlusion revascularization: A complex piece to "complete" the puzzle. World J Cardiol 2022; 14:13-28. [PMID: 35126869 PMCID: PMC8788177 DOI: 10.4330/wjc.v14.i1.13] [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: 03/17/2021] [Revised: 07/15/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of “contemporary” strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a “complex” piece to “complete” the puzzle.
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Affiliation(s)
- Iacopo Muraca
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Nazario Carrabba
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giacomo Virgili
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Filippo Bruscoli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Angela Migliorini
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Matteo Pennesi
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giulia Pontecorboli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Niccolò Marchionni
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Renato Valenti
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
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Kovach CP, Hebbe A, Barón AE, Strobel A, Plomondon ME, Valle JA, Waldo SW. Clinical Characteristics and Outcomes Among Patients Undergoing High-Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2021; 10:e022131. [PMID: 34775783 PMCID: PMC9075385 DOI: 10.1161/jaha.121.022131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background High-risk percutaneous coronary intervention (HR-PCI) is increasingly common among contemporary patients with coronary artery disease. Experts have advocated for a collaborative 2-operator approach to support intraprocedural decision-making for these complex interventions. The impact of a second operator on patient and procedural outcomes is unknown. Methods and Results Patients who underwent HR-PCI from 2015 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity-matched cohorts were generated to compare the outcomes following HR-PCI performed by a single or multiple (≥2) operators. The primary end point was the 12-month rate of major adverse cardiovascular events. We identified 6672 patients who underwent HR-PCI during the study period; 6211 (93%) were treated by a single operator, and 461 (7%) were treated by multiple operators, with a nonsignificant trend toward increased multioperator procedures over time. A higher proportion of patients treated by multiple operators underwent left main (10% versus 7%, P=0.045) or chronic total occlusion intervention (11% versus 5%, P<0.001). Lead interventionalists participating in multioperator procedures practiced at centers with higher annual HR-PCI volumes (124±71.3 versus 111±69.2; standardized mean difference, 0.197; P<0.001) but otherwise performed a similar number of HR-PCI procedures per year (34.4±35.3 versus 34.7±30.7; standardized mean difference, 0.388; P=0.841) compared with their peers performing single-operator interventions. In a propensity-matched cohort, there was no significant difference in major adverse cardiovascular events (32% versus 30%, P=0.444) between patients who underwent single-operator versus multioperator HR-PCI. Adjusted analyses accounting for site-level variance showed no significant differences in outcomes. Conclusions Patients who underwent multioperator HR-PCI had similar outcomes compared with single-operator procedures. Further studies are needed to determine if the addition of a second operator offers clinical benefits to a subset of HR-PCI patients undergoing left main or chronic total occlusion intervention.
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Affiliation(s)
| | - Annika Hebbe
- Department of Biostatistics and Informatics University of Colorado Aurora CO.,CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
| | - Anna E Barón
- Department of Biostatistics and Informatics University of Colorado Aurora CO
| | - Aaron Strobel
- Division of Cardiology Department of Medicine University of Colorado Aurora CO
| | - Mary E Plomondon
- CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
| | - Javier A Valle
- Division of Cardiology Department of Medicine University of Colorado Aurora CO.,Department of Medicine, Michigan Heart and Vascular Institute Ann Arbor MI
| | - Stephen W Waldo
- Division of Cardiology Department of Medicine University of Colorado Aurora CO.,CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
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11
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Elia E, Iannaccone M, D'Ascenzo F, Gallone G, Colombo F, Albani S, Attisani M, Rinaldi M, Boccuzzi G, Conrotto F, Noussan P, De Ferrari GM. Short term outcomes of Impella circulatory support for high-risk percutaneous coronary intervention a systematic review and meta-analysis. Catheter Cardiovasc Interv 2021; 99:27-36. [PMID: 34028964 DOI: 10.1002/ccd.29757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/24/2021] [Accepted: 05/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Aim of this study is to evaluate short term safety and efficacy of Impella in high risk percutaneous coronary intervention (HR-PCI) population. BACKGROUND While several studies demonstrated the clinical significance of Impella in HR-PCI, few data exist about its impact on short term outcome. METHODS All studies reporting short term outcomes of PCI with any Impella device were included. The primary endpoint was either in-hospital or 30-day mortality, while vascular complications, post-procedural stroke, post-procedural dialysis and bleeding complications were assessed as secondary outcomes. RESULTS Nine studies with 7448 patients were included. Median age was 69.5 years old (67-73), with a mean ejection fraction of 29.7% (20%-39%) and a Syntax score of 30.2 (25. 5-33, interquartile [IQR]). Impella 2.5 was the most commonly used axial flow pump used to support these PCIs (88.7%). In-hospital death was observed in 5.09% of patients (95% confidence interval [CI] 3.69-6.49, I2 = 78%), while vascular complications in 2.53% of patients (1.07-4.00, I2 = 89%) and post-procedural stroke in 2.77% of patients (0.50-6.05, I2 = 98%). Major bleeding occurred in 5.98% of patients (3.66-8.31, I2 = 90%) and post-procedural dialysis in 4.44% of patients (1.50-7.37, I2 = 93% all CI 93%). CONCLUSION Use of Impella in high risk PCI appears to have an acceptable rate of complication, especially regarding vascular complications and major bleedings.
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Affiliation(s)
- Edoardo Elia
- Division of Cardiology, Department of Medical Science, University of Turin, Turin, Italy
| | - Mario Iannaccone
- Division of Cardiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science, University of Turin, Turin, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Medical Science, University of Turin, Turin, Italy
| | | | - Stefano Albani
- Division of Cardiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Matteo Attisani
- Department of Cardiac Surgery, AOU "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Mauro Rinaldi
- Department of Cardiac Surgery, AOU "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Giacomo Boccuzzi
- Division of Cardiology, Ospedale San Giovanni Bosco, Turin, Italy
| | | | - Patrizia Noussan
- Division of Cardiology, Ospedale San Giovanni Bosco, Turin, Italy
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12
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Retrograde Dissection and Reentry: Strategies: Common Pitfalls and Troubleshooting. Interv Cardiol Clin 2020; 10:51-64. [PMID: 33223106 DOI: 10.1016/j.iccl.2020.09.004] [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: 11/22/2022]
Abstract
The retrograde dissection reentry (RDR) technique is often required to treat the most complex chronic total occlusions (CTOs). This involves a sequence of procedural steps with many potential pitfalls. Procedural planning, knowledge of the equipment, including task-specific wires and microcatheters, and the ability to systematically trouble shoot is necessary to achieve consistent success. With the combination of more complex anatomy and collateral crossing, RDR is associated with higher rates of procedural complications, which the CTO operator must be specifically trained to avoid and to manage.
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13
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Nikolakopoulos I, Vemmou E, Karacsonyi J, Xenogiannis I, Werner GS, Gershlick AH, Rinfret S, Yamane M, Avran A, Egred M, Garcia S, Burke MN, Brilakis ES. Latest developments in chronic total occlusion percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2020; 18:415-426. [PMID: 32594784 DOI: 10.1080/14779072.2020.1787153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates. AREAS COVERED We describe recent clinical and technological developments in CTO PCI from 2018 to 2020. EXPERT OPINION After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.
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Affiliation(s)
- Ilias Nikolakopoulos
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Evangelia Vemmou
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Iosif Xenogiannis
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Gerald S Werner
- Medizinische Klinik I (Cardiology & Intensive Care), Klinikum Darmstadt GmbH , Darmstadt, Germany
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester and National Institute of Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital , Leicester, UK
| | - Stephane Rinfret
- McGill University Health Centre, McGill University , Montreal, Quebec, Canada
| | - Masahisa Yamane
- Cardiology Department, Saitama Sekishinkai Hospital , Saitama, Japan
| | - Alexandre Avran
- Department of Interventional Cardiology, Clinique Pasteur, Essey-lès-nancy , France
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Newcastle University , Newcastle-Upon-Tyne, UK
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital , Minneapolis, MN, USA
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14
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Doll JA, Hira RS, Kearney KE, Kandzari DE, Riley RF, Marso SP, Grantham JA, Thompson CA, McCabe JM, Karmpaliotis D, Kirtane AJ, Lombardi W. Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle Percutaneous Coronary Intervention Complications Conference. Circ Cardiovasc Interv 2020; 13:e008962. [PMID: 32527193 DOI: 10.1161/circinterventions.120.008962] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Complications of percutaneous coronary intervention (PCI) may have significant impact on patient survival and healthcare costs. PCI procedural complexity and patient risk are increasing, and operators must be prepared to recognize and treat complications, such as perforations, dissections, hemodynamic collapse, no-reflow, and entrapped equipment. Unfortunately, few resources exist to train operators in PCI complication management. Uncertainty regarding complication management could contribute to the undertreatment of patients with high-complexity coronary disease. We, therefore, coordinated the Learning From Complications: How to Be a Better Interventionalist courses to disseminate the collective experience of high-volume PCI operators with extensive experience in chronic total occlusion and high-risk PCI. From these conferences in 2018 and 2019, we developed algorithms that emphasize early recognition, effective treatment, and team-based care of PCI complications. We think that an algorithmic approach will result in a logical and systematic response to life-threatening complications. This construct may be useful for operators who plan to perform complex PCI procedures.
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Affiliation(s)
- Jacob A Doll
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.).,VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Ravi S Hira
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | - Kathleen E Kearney
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Robert F Riley
- The Christ Hospital Health Network, Cincinnati, OH (R.F.R.)
| | - Steven P Marso
- HCA Midwest Health Heart and Vascular Institute, Overland Park, KS (S.P.M.)
| | - James A Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.).,University of Missouri-Kansas City, Kansas City, MO (J.A.G.)
| | | | - James M McCabe
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
| | | | - Ajay J Kirtane
- Columbia University Medical Center, New York, NY (D.K., A.J.K.)
| | - William Lombardi
- University of Washington, Seattle, WA (J.A.D., R.S.H., K.E.K., J.M.M., W.L.)
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15
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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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17
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Vetrovec GW, Kaki A, Dahle TG. A Review of Bleeding Risk with Impella-supported High-risk Percutaneous Coronary Intervention. Heart Int 2020; 14:92-99. [DOI: 10.17925/hi.2020.14.2.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022] Open
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