Ejection Fraction Improvement Following Contemporary High-Risk Percutaneous Coronary Intervention: RESTORE EF Study Results

Role of Mechanical Circulatory Support in Complex High-Risk and Indicated Percutaneous Coronary Intervention: Current Indications, Device Options, and Potential Complications

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.

Complete percutaneous coronary revascularization: An elegant solution to left ventricular dysfunction caused by severe coronary artery disease

With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.

Predictors of left ventricular ejection fraction in high-risk percutaneous coronary interventions

Revascularization completeness after percutaneous coronary intervention (PCI) is associated with improved long-term outcomes. Mechanical circulatory support [intra-aortic balloon pump (IABP) or Impella] is used during high-risk PCI (HR-PCI) to enhance peri-procedural safety and achieve more complete revascularization. The relationship between revascularization completeness [post-PCI residual SYNTAX Score (rSS)] and left ventricular ejection fraction (LVEF) in HR-PCI has not been established. We investigated LVEF predictors at 90 days post-PCI with Impella or IABP support. Individual patient data (IPD) were analyzed from PROTECT II (NCT00562016) in the base case. IPD from PROTECT II and RESTORE-EF (NCT04648306) were naïvely pooled in the sensitivity analysis. Using complete cases only, linear regression was used to explore the predictors of LVEF at 90 days post-PCI. Models were refined using stepwise selection based on Akaike Information Criterion and included: treatment group (Impella, IABP), baseline characteristics [age, gender, race, New York Heart Association Functional Classification, LVEF, SYNTAX Score (SS)], and rSS. Impella treatment and higher baseline LVEF were significant predictors of LVEF improvement at 90 days post-PCI (p ≤ 0.05), and a lower rSS contributed to the model (p = 0.082). In the sensitivity analysis, Impella treatment, higher baseline LVEF, and lower rSS were significant predictors of LVEF improvement at 90 days (p ≤ 0.05), and SS pre-PCI contributed to the model (p = 0.070). Higher baseline LVEF, higher SS pre-PCI, lower rSS (i.e. completeness of revascularization), and Impella treatment were predictors of post-PCI LVEF improvement. The findings suggest potential mechanisms of Impella include improving the extent and quality of revascularization, and intraprocedural ventricular unloading.

Current Landscape and Future Directions of Coronary Revascularization in Ischemic Systolic Heart Failure: A Review

Ischemic heart disease is the largest cause of death worldwide and the most common cause of heart failure (HF). The incidence and prevalence of HF are increasing owing to an aging population and improvements in the acute cardiac care of previously fatal conditions such as myocardial infarction. Strategies to improve outcomes in patients with ischemic systolic HF are urgently needed. There is systematic underutilization of testing for coronary artery disease in patients with HF, and revascularization is performed in an even smaller minority despite evidence for reduced mortality with coronary artery bypass grafting (CABG) over medical therapy in the Surgical Treatment for Ischemic Heart Failure Extension Study. Percutaneous coronary intervention (PCI) is a less-invasive approach to coronary revascularization; however, the recent Revascularization for Ischemic Ventricular Dysfunction (REVIVED)-British Cardiovascular Intervention Society (BCIS2) trial failed to demonstrate a benefit of PCI compared with that of medical therapy in patients with ischemic systolic HF. The comparative effectiveness of PCI and CABG for patients with ischemic systolic HF remains unknown, particularly in the era of contemporary medical therapy. In this review, we discuss the benefit of CABG in ischemic systolic HF, its underutilization, and the unmet clinical need. We also review the recent REVIVED-BCIS2 trial comparing PCI to medical therapy, as well as upcoming randomized controlled trials of PCI for ischemic systolic HF and persistent evidence gaps that will exist despite anticipated data from ongoing trials. There remains a need for an adequately powered randomized controlled trials to establish the comparative clinical effectiveness of PCI vs CABG in ischemic systolic HF in the era of contemporary revascularization approaches and medical therapy, as well as trials of coronary revascularization in patients with HF with preserved ejection fraction or less severe forms of left ventricular systolic dysfunction.

[The Role of the Percutaneous Impella Pump in Anesthesia and Intensive Care]

The use of temporary mechanical circulatory support (tMCS) devices and in particular the increasing use of the Impella device family has gained significant interest over the last two decades. Nowadays, its use plays a well-established key role in both the treatment of cardiogenic shock, and as a preventive and protective therapeutic option during high-risk procedures in both cardiac surgery and cardiology, such as complex percutaneous interventions (protected PCI). Thus, it is not surprising that the Impella device is more and more present in the perioperative setting and especially in patients on intensive care units. Despite the numerous advantages such as cardiac resting and hemodynamic stabilization, potential adverse events exist, which may lead to severe, but preventable complications, so that adequate education, early recognition of such events and a subsequent adequate management are crucial in patients with tMCS. This article provides an overview especially for anesthesiologists and intensivists focusing on technical basics, indications and contraindications for its use with special focus on the intra- and postoperative management. Furthermore, troubleshooting for most common complications for patients on Impella support is provided.

Predicting left ventricular functional recovery in ischaemic cardiomyopathy: needs and challenges

Left ventricular (LV) systolic function is an essential parameter for the evaluation of patients with ischaemic heart disease, and therapeutic choices are significantly driven by LV ejection fraction (LVEF) in the early stage of the disease and during follow-up. After an acute coronary syndrome, ventricular dysfunction may be reversible when caused by transient myocardial stunning. Therefore, the identification of clinical, laboratory, and instrumental predictors of improvement in LV systolic function (in addition to LVEF) is essential for an adequate prognostic stratification. In the setting of chronic ischaemic heart disease, there is no evidence that an improvement in LV systolic function is invariably associated with a better prognosis and LVEF is only one of many parameters that should be considered for the risk stratification. This state-of-the-art review will critically analyse the scientific evidence regarding known predictors of LVEF recovery, trying to elucidate their pathophysiological principles and clinical value.