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Vetrovec GW, Kaki A, Wollmuth J, Dahle TG. Strategies for Reducing Vascular and Bleeding Risk for Percutaneous Left Ventricular Assist Device-supported High-risk Percutaneous Coronary Intervention. Heart Int 2022; 16:105-111. [PMID: 36741103 PMCID: PMC9872781 DOI: 10.17925/hi.2022.16.2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022] Open
Abstract
In patients at high risk for haemodynamic instability during percutaneous coronary intervention (PCI), practitioners are increasingly opting for prophylactic mechanical circulatory support, such as the Impella® heart pump (Abiomed, Danvers, MA, USA). Though Impella-supported high-risk PCI (HRPCI) ensures haemodynamic stability during the PCI procedure, access-related complication rates have varied significantly in published studies. Reported variability in complication rates relates to many factors, including anticoagulation practices, access and closure strategy, post-procedure care and variations in event definitions. This article aims to outline optimal strategies to minimize vascular and bleeding complications during Impella-supported HRPCI based on previously identified clinical, procedural and postprocedural risk factors. Practices to reduce complications include femoral skills training, standardized protocols to optimize access, closure, anticoagulation management and post-procedural care, as well as the application of techniques and technological advances. Protocols integrating these strategies to mitigate access-related bleeding and vascular complications for Impella-supported procedures can markedly limit vascular access risk as a barrier to appropriate large-bore mechanical circulatory support use in HRPCI.
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Affiliation(s)
- George W Vetrovec
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Amir Kaki
- Division of Cardiology, St. John’s Hospital, Wayne State University, Detroit, MI, USA
| | - Jason Wollmuth
- Providence Heart and Vascular Institute, Providence, OR, USA
| | - Thom G Dahle
- CentraCare Heart & Vascular Center, St. Cloud Hospital, St. Cloud, MN, USA
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O'Neill BP, Grines C, Moses JW, Ohman EM, Lansky A, Popma J, Kapur NK, Schreiber T, Mannino S, O'Neill WW, Medjamia AM, Mahmud E. Outcomes of bailout percutaneous ventricular assist device versus prophylactic strategy in patients undergoing nonemergent percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:E501-E512. [PMID: 34051033 DOI: 10.1002/ccd.29758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/18/2021] [Accepted: 05/03/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare in-hospital outcomes of bailout support to prophylactic support with percutaneous ventricular assist devices (pVAD) for high-risk nonemergent percutaneous coronary intervention (HRPCI). BACKGROUND Prophylactic support with pVAD for a HRPCI is used in patients felt to be at risk for hemodynamic collapse during PCI. An alternative strategy of bailout pVAD support in the event of hemodynamic collapse is also entertained. METHODS We compared the outcomes of patients entered in the cVAD database who underwent Impella Protected PCI (ProPCI group) with patients from the cVAD and USpella databases receiving bailout Impella support for hemodynamic collapse during HRPCI (Bailout group). RESULTS A total of 1,028 patients supported with Impella pVAD were entered into the cVAD database as of July 2019 and were included in this analysis. Of those 971 were in the ProPCI group and 57 in the Bailout group. Patients in the Bailout group were more often female (50.9%vs. 27.2%, p = .0002) with higher median baseline left ventricular ejection fraction (LVEF) (40%vs. 30%, p < .0001) and with lower prevalence of both heart failure (42.1%vs. 56.9%, p = .0385) and left main disease (40.0%vs. 56.1%, p = .0250) compared to the ProPCI group. Unadjusted and adjusted in-hospital mortality was significantly higher in the Bailout group (49.1%vs. 4.3%, and 57.8%vs. 4.4%, p < .0001 for both). CONCLUSIONS In our study population, the bailout group was associated with significant increased mortality compared to ProPCI group. Female gender was more frequently observed in patients requiring bailout pVAD. Further investigation is warranted in order to generalize the findings of our study.
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Affiliation(s)
- Brian P O'Neill
- Department of Cardiology, Henry Ford Hospital Center for Structural Heart, Detroit, Michigan, USA
| | - Cindy Grines
- Department of Cardiology, Northside cardiovascular institute, Atlanta, Georgia, USA
| | - Jeffrey W Moses
- Department of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - E Magnus Ohman
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexandra Lansky
- Department of Cardiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffery Popma
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Navin K Kapur
- Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, Massachusetts, USA
| | - Theodore Schreiber
- Department of Cardiology, Ascension St. John Hospital, Warren, Michigan, USA
| | - Salvatore Mannino
- Department of Cardiology, WellStar Kennestone Hospital, Marietta, Georgia, USA
| | - William W O'Neill
- Department of Cardiology, Henry Ford Hospital Center for Structural Heart, Detroit, Michigan, USA
| | - Amin M Medjamia
- Department of Medical Affairs and Clinical Research, Abiomed Inc., Danvers, Massachusetts, USA
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
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Simonton C, Thompson C, Wollmuth JR, Morris DL, Dahle TG. The Role of Hemodynamic Support in High-risk Percutaneous Coronary Intervention. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2020.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with advanced age, complex coronary anatomy, and multiple comorbidities are often unsuitable for surgical revascularization. In this setting, hemodynamic support devices are used as an adjunct to percutaneous coronary intervention to maintain hemodynamic stability and enable optimal revascularization. This article provides an overview of percutaneous hemodynamic support devices currently used in clinical practice for high-risk percutaneous coronary intervention. These include the intra-aortic balloon pump, centrifugal pumps (TandemHeart, venous arterial extracorporeal membrane oxygenation), and micro-axial Impella pump. The hemodynamic effects, clinical evidence supporting improved outcomes and recovery of heart function, and associated complications with these devices are highlighted, with a special focus on Impella pumps.
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Affiliation(s)
| | | | | | - D Lynn Morris
- East Carolina Heart Institute Brody School of Medicine, Greenville, NC
| | - Thom G Dahle
- Centracare Heart and Vascular Center, St Cloud, MN
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Patel N, Sharma A, Dalia T, Rali A, Earnest M, Tadros P, Wiley M, Hockstad E, Mehta A, Thors A, Hance K, Gupta K. Vascular complications associated with percutaneous left ventricular assist device placement: A 10-year US perspective. Catheter Cardiovasc Interv 2019; 95:309-316. [PMID: 31638737 DOI: 10.1002/ccd.28560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Over the last decade, there has been a significant increase in the use of percutaneous left ventricular assist devices(p-LVADs). p-LVADs are being increasingly used during complex coronary interventions and for acute cardiogenic shock. These large bore percutaneous devices have a higher risk of vascular complications. We examined the vascular complication rates from the use of p-LVAD in a national database. METHODS We conducted a secondary analysis of the National In-patient Sample (NIS) dataset from 2005 till 2015. We used the ICD-9-CM procedure codes 37.68 and 37.62 for p-LVAD placement regardless of indications. We investigated common vascular complications, defining them by the validated ICD 9 CM codes. χ2 test and t test were used for categorical and continuous variables, respectively for comparison. RESULTS A total of 31,263 p-LVAD placements were identified during the period studied. A majority of patients were male (72.68%) and 64.44% were white. The overall incidence of vascular complications was 13.53%, out of which 56% required surgical treatment. Acute limb thromboembolism and bleeding requiring transfusion accounted for 27.6% and 21.8% of all vascular complications. Occurrence of a vascular complication was associated with significantly higher in-hospital mortality (37.77% vs. 29.95%, p < .001), length of stay (22.7 vs. 12.2 days, p < .001) and cost of hospitalization ($ 161,923 vs. $ 95,547, p < .001). CONCLUSIONS There is a high incidence of vascular complications with p-LVAD placement including need for vascular surgery. These complications are associated with a higher in-hospital, LOS and hospitalization costs. These findings should be factored into the decision-making for p-LVAD placement.
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Affiliation(s)
- Nilay Patel
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Akshit Sharma
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Tarun Dalia
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Aniket Rali
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Earnest
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter Tadros
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Mark Wiley
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Eric Hockstad
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Ashwani Mehta
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Axel Thors
- Vascular Surgery Division, University of Kansas Medical Center, Kansas City, Kansas
| | - Kirk Hance
- Vascular Surgery Division, University of Kansas Medical Center, Kansas City, Kansas
| | - Kamal Gupta
- Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
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Shah Z, Alraies MC, Soud M, Kaki A. Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath. Catheter Cardiovasc Interv 2019; 93:673-677. [PMID: 30549188 DOI: 10.1002/ccd.28022] [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: 09/19/2018] [Revised: 11/17/2018] [Accepted: 11/25/2018] [Indexed: 11/06/2022]
Abstract
Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large-bore arterial accesses. Large-bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48-year-old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex-vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.
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Affiliation(s)
- Zeel Shah
- School of Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - M Chadi Alraies
- School of Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Mohamad Soud
- MedStar Washington Hospital Center, Washington, District of Columbia
| | - Amir Kaki
- St. John Hospital and Medical Center, Detroit, Michigan
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Montone RA, Niccoli G. Percutaneous coronary intervention in patients refused from surgery: a different entity? Minerva Cardioangiol 2018. [DOI: 10.23736/s0026-4725.18.04656-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pesarini G, Gratta A, Dolci G, Lunardi M, Ribichini FL. Impella-protected PCI: the clinical results achieved so far. Minerva Cardioangiol 2018; 66:612-618. [PMID: 29642690 DOI: 10.23736/s0026-4725.18.04678-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The ability of interventional cardiologists to identify high-risk percutaneous coronary intervention (PCI) patients, requires the integration of different features belonging to medical history, organ damage, coronary anatomy and the nature of the acute event. The selection of a subgroup of patients that could benefit from mechanical support during interventions is a key feature to success. The introduction of the Impella percutaneous axial pump have added an easy-to-set-up, less invasive and time-consuming active-support device to the interventional toolbox. Up to date, only few (four) randomized clinical trials (RCTs) have tried to address the clinical efficacy of Impella assistance for the treatment of this very high-risk population, but several large registries and multiple observational studies have demonstrated its safety, feasibility and hemodynamic performance. Although the largest RCT (PROTECT II) have been prematurely stopped due to the risk of futility despite the evidence of more complete revascularization in the Impella arm, the need for an adequate operator's learning curve must be considered. More recent insights suggest an effect of the device in optimizing end-organ perfusion and improving crucial parameters like renal function. Furthermore, available data suggest that vary early Impella support may improve patient's outcome in case of cardiogenic shock.
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Affiliation(s)
- Gabriele Pesarini
- Cardiovascular Interventional Unit, Division of Cardiology, University of Verona, Verona, Italy
| | - Andrea Gratta
- Cardiovascular Interventional Unit, Division of Cardiology, University of Verona, Verona, Italy
| | - Giulia Dolci
- Cardiovascular Interventional Unit, Division of Cardiology, University of Verona, Verona, Italy
| | - Mattia Lunardi
- Cardiovascular Interventional Unit, Division of Cardiology, University of Verona, Verona, Italy
| | - Flavio L Ribichini
- Cardiovascular Interventional Unit, Division of Cardiology, University of Verona, Verona, Italy -
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Expertenkonsensus zum praktischen Einsatz von Herzkreislaufunterstützungssystemen bei Hochrisiko‑Koronarinterventionen. KARDIOLOGE 2017. [DOI: 10.1007/s12181-017-0208-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
Heart failure (HF) remains the leading cause of hospitalization in older adults and is associated with increased morbidity and mortality despite the use of guideline-directed medical therapy. There has been tremendous progress in the development of novel transcatheter and interventional therapies for HF over the past decade. The evolution of structural heart disease interventions and interventional HF has led to a multidisciplinary heart team approach in the management of HF patients. Careful selection of the appropriate patient population and end points in future randomized controlled trials will be crucial to demonstrate the potential efficacy of the novel interventional HF therapies.
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Affiliation(s)
- Dhaval Kolte
- Division of Cardiovascular Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Jinnette Dawn Abbott
- Division of Cardiovascular Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA.
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MacKay EJ, Patel PA, Gutsche JT, Weiss SJ, Augoustides JG. Contemporary Clinical Niche for Intra-Aortic Balloon Counterpulsation in Perioperative Cardiovascular Practice: An Evidence-Based Review for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth 2017; 31:309-320. [DOI: 10.1053/j.jvca.2016.07.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Indexed: 01/10/2023]
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Briceno N, Kapur NK, Perera D. Percutaneous mechanical circulatory support: current concepts and future directions. Heart 2016; 102:1494-507. [DOI: 10.1136/heartjnl-2015-308562] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Abaunza M, Kabbani LS, Nypaver T, Greenbaum A, Balraj P, Qureshi S, Alqarqaz MA, Shepard AD. Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device. J Vasc Surg 2015; 62:417-23. [DOI: 10.1016/j.jvs.2015.03.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/18/2015] [Indexed: 11/25/2022]
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