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Reddy P, Merdler I, Zhang C, Cellamare M, Ben-Dor I, Bernardo NL, Hashim HD, Satler LF, Rogers T, Waksman R. Impella Versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention. Am J Cardiol 2024; 225:4-9. [PMID: 38871158 DOI: 10.1016/j.amjcard.2024.05.038] [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] [Received: 04/09/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
The benefit of mechanical circulatory support with Impella (Abiomed, Inc., Danvers, Massachusetts) for high-risk percutaneous coronary intervention (HR-PCI) is uncertain. PROTECT III registry data showed improved outcomes with Impella compared with historical data (PROTECT II) but lack a direct comparison with the HR-PCI cohort without Impella support. We retrospectively identified patients meeting the PROTECT III inclusion criteria for HR-PCI and compared this group (non-Impella cohort [NonIMP]) with the outcomes data from the PROTECT III registry (Impella cohort). Baseline differences were balanced using inverse propensity weighting. The coprimary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. A total of 283 patients at great risk did not receive Impella support; 200 patients had 90-day event ascertainment and were included in the inverse propensity weighting analysis and compared with 504 patients in the Impella cohort group. After calibration, few residual differences remained between groups. The primary outcome was not different in-hospital (3.0% vs 4.8%, p = 0.403) but less in NonIMP at 90 days (7.5% vs 13.8%, p = 0.033). Periprocedural vascular complications, bleeding, and transfusion rate did not differ between groups; however, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs 5.4%, p = 0.023). In conclusion, under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella-supported HR-PCI cohort showed similar MACE in-hospital but fewer MACE at 90 days, whereas there was no signal for periprocedural harm with Impella use. These results do not support routine usage of Impella for patients with HR-PCI.
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Affiliation(s)
- Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Matteo Cellamare
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Hayder D Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
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Chitturi KR, Zhang C, Abusnina W, Sawant V, Banerjee A, Ahmed S, Merdler I, Haberman D, Chaturvedi A, Lupu L, Reddy P, Case BC, Rogers T, Hashim HD, Ben-Dor I, Bernardo NL, Satler LF, Waksman R. High-risk percutaneous coronary intervention with or without mechanical circulatory support: Will Impella show superiority in the PROTECT IV randomized trial? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00580-3. [PMID: 39013705 DOI: 10.1016/j.carrev.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND PROTECT IV is a current enrolling randomized controlled trial evaluating high-risk percutaneous coronary intervention (HR-PCI) with prophylactic Impella versus no Impella to reduce the composite primary endpoint of all-cause death, stroke, myocardial infarction (MI), or cardiovascular hospitalization. In a PROTECT IV-like cohort of patients who underwent HR-PCI without Impella, we aimed to report the rate of major adverse events to determine whether the trial is adequately powered. METHODS AND RESULTS A total of 700 patients meeting similar inclusion/exclusion criteria of PROTECT IV who underwent HR-PCI without Impella at a single tertiary center from 2008 to 2022 were included in the analysis. The composite rates of all-cause death, MI, target lesion revascularization, and target vessel revascularization at 1, 2, and 3 years were estimated using the Kaplan-Meier method, and the results were used to calculate the sample size under the constant hazard ratio assumption and expected number of events to be observed used in planning PROTECT IV. The primary endpoint occurred in 30.8 % of patients at 2 years. PROTECT IV assumes a hazard ratio of 0.75 using a multivariate Cox regression, which, under a 5 % level and 90 % power, yields 516 events. This implies a 2-year primary outcome rate of 50 % for the non-Impella arm. CONCLUSION Therefore, PROTECT IV estimates that a sample size of 1252 patients is required for Impella to be declared superior to the non-Impella group. Using our observed 2-year outcome of 30.8 %, we estimate that PROTECT IV requires 1966 patients, demonstrating that PROTECT IV is probably underpowered.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Vaishnavi Sawant
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Avantika Banerjee
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Shaan Ahmed
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Dan Haberman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Lior Lupu
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Hayder D Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
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Haschemi J, Oehler D, Haurand JM, Voss F, Polzin A, Kelm M, Horn P. Outcome of Patients Managed by Percutaneous Left Ventricular Assist Device Implantation During On-Hours and Off-Hours. ASAIO J 2024; 70:193-198. [PMID: 37862685 DOI: 10.1097/mat.0000000000002081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
Percutaneous left ventricular assist devices (pVADs) may be used in patients with cardiogenic shock (CS) to stabilize hemodynamics and maintain sufficient end-organ perfusion. Vascular complications are commonly observed in patients with pVAD support. We aimed to assess the relationship between pVAD implantation time and access-site complication rates. This retrospective observational study included all patients who underwent pVAD insertion for the treatment of CS at our university hospital between 2014 and 2021 (n = 224). Depending on the pVAD insertion time, the patients were assigned to the on-hours (n = 120) or off-hours group (n = 104). Both groups had comparable baseline characteristics and comorbidities. The rate of access-site-related complications was higher in the off-hours group than in the on-hours group (26% vs. 10%, p = 0.002). Premature discontinuation of pVAD support to prevent limb ischemia or manage access-site bleeding was required more often in the off-hours group than in the on-hours group (14% vs. 5%, p = 0.016). Pre-existing peripheral artery disease and implantation time off-hours were independent predictors for access-siterelated vascular complications. In conclusion, patients with CS in whom pVAD was inserted during off-hours had higher rates of access-site-related complications and premature discontinuation of pVAD support than those in whom pVAD was inserted during on-hours.
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Affiliation(s)
- Jafer Haschemi
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jean Marc Haurand
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Fabian Voss
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University, Düsseldorf, Germany
| | - Patrick Horn
- From the Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Sandoval Y, Basir MB, Lemor A, Lichaa H, Alasnag M, Dupont A, Hirst C, Kearney KE, Kaki A, Smith TD, Vallabhajosyula S, Kayssi A, Firstenberg MS, Truesdell AG. Optimal Large-Bore Femoral Access, Indwelling Device Management, and Vascular Closure for Percutaneous Mechanical Circulatory Support. Am J Cardiol 2023; 206:262-276. [PMID: 37717476 DOI: 10.1016/j.amjcard.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/30/2023] [Accepted: 08/05/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Alejandro Lemor
- Department of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hady Lichaa
- Ascension Saint Thomas Heart, Ascension Saint Thomas Rutherford, Murfreesboro, Tennessee
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Colin Hirst
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | | | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Khuddus MA, Basir MB, Palmer A, Edidin A. Suture-Mediated Intermediate and Terminal Closure When Using the Aortix Percutaneous Mechanical Circulatory Support Device. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101038. [PMID: 39132400 PMCID: PMC11307409 DOI: 10.1016/j.jscai.2023.101038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/09/2023] [Accepted: 04/28/2023] [Indexed: 08/13/2024]
Abstract
Background The Aortix percutaneous mechanical circulatory support (pMCS) 18F micromechanical axial impeller-driven pump is percutaneously placed and retrieved from the descending aorta above the renal arteries. Pump deployment and retrieval use defined steps to allow suture-mediated closure around the exiting power lead and for terminal hemostasis after device retrieval after therapy. The overall procedure was validated preclinically in ovine and porcine models and has since proven reliable in a recently completed IDE feasibility study (NCT04145635). This study describes the steps of a novel technique for reliable suture-mediated vessel closure when using the Aortix pMCS device. Methods The principal steps associated with the procedure comprised ultrasound-guided access of the femoral artery, preclose placement of 4 Perclose (Abbott) sutures, achievement of intermediate hemostasis by locking 3 of the 4 sutures around the 6F exiting power lead, breaking the 3 locked sutures to permit vessel reentry for device removal, and finally, vessel closure using the fourth preclose suture along with 1 or more postclose suture(s) to close the femoral artery using a hybrid dual-sheath technique. Results The standardized steps described have been developed and used over the course of 21 clinical cases by 12 operators who were initially procedurally naïve but experienced in large-bore access. Conclusions Preclose and postclose suture-mediated closure is a reliable means of managing the exiting power lead of the Aortix pMCS and closing the large-bore arteriotomy after pump retrieval. The steps outlined in this study may have applicability to other procedures requiring large-bore access or using suture-mediated closure.
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Affiliation(s)
| | - Mir B. Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Aaron Palmer
- Product Development, Procyrion, Inc, Houston, Texas
| | - Av Edidin
- Product Development, Procyrion, Inc, Houston, Texas
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Saleem D, Sethi SS, Parikh SA, Madhavan MV, Gogia S, Fried J, Uriel N, Kirtane AJ, Finn MT. Preclose Cinching "C-Stitch" to Aid Hemostasis After Impella Insertion. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100447. [PMID: 39132341 PMCID: PMC11307742 DOI: 10.1016/j.jscai.2022.100447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 08/13/2024]
Affiliation(s)
- Danial Saleem
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Sanjum S. Sethi
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - Sahil A. Parikh
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - Mahesh V. Madhavan
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - Shawn Gogia
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Justin Fried
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - Ajay J. Kirtane
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | - Matthew T. Finn
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
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Tan SR, Low CJW, Ng WL, Ling RR, Tan CS, Lim SL, Cherian R, Lin W, Shekar K, Mitra S, MacLaren G, Ramanathan K. Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101629. [PMID: 36295065 PMCID: PMC9605512 DOI: 10.3390/life12101629] [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: 09/30/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.
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Affiliation(s)
- Shien Ru Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Wei Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119228, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Saikat Mitra
- Intensive Care Unit, Dandenong and Casey Hospital, Monash Health, Melbourne, VIC 3175, Australia
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
- Correspondence:
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Velagapudi P, El Sabbagh A. Where There Is Not 'Pre-Closure', Will 'Post-Closure' Tackle it?! CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 39:43-44. [PMID: 35379568 DOI: 10.1016/j.carrev.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 01/04/2023]
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