Percutaneous mechanical circulatory support devices in high-risk patients undergoing percutaneous coronary intervention: A meta-analysis of randomized trials

Effects of mechanical circulatory support devices in patients with acute myocardial infarction undergoing stent implantation: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The survival benefit of using mechanical circulatory support (MCS) in patients with acute myocardial infarction (AMI) is still controversial. It is necessary to explore the impact on clinical outcomes of MCS in patients with AMI undergoing stenting.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Cochrane Library, Medline, PubMed, Web of Science, ClinicalTrials.gov and Clinicaltrialsregister.eu databases were searched from database inception to February 2021.

ELIGIBILITY CRITERIA

Randomised clinical trials (RCTs) on MCS use in patients with AMI undergoing stent implantation were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and summarised independently by two reviewers. Risk ratios (RRs) and 95% CIs were calculated for clinical outcomes according to random-effects model.

RESULTS

Twelve studies of 1497 patients with AMI were included, nine studies including 1382 patients compared MCS with non-MCS, and three studies including 115 patients compared percutaneous ventricular assist devices (pVADs) versus intra-aortic balloon pump (IABP). Compared with non-MCS, MCS was not associated with short-term (within 30 days) (RR=0.90; 95% CI 0.57 to 1.41; I²=46.8%) and long-term (at least 6 months) (RR=0.82; 95% CI 0.57 to 1.17; I²=37.6%) mortality reductions. In the subset of patients without cardiogenic shock (CS) compared with non-MCS, the patients with IABP treatment significantly had decreased long-term mortality (RR=0.49; 95% CI 0.27 to 0.90; I²=0), but without the short-term mortality reductions (RR=0.51; 95% CI 0.22 to 1.19; I²=17.9%). While in the patients with CS, the patients with MCS did not benefit from the short-term (RR=1.09; 95% CI 0.67 to 1.79; I²=46.6%) or long-term (RR=1.00; 95% CI 0.75 to 1.33; I²=22.1%) survival. Moreover, the application of pVADs increased risk of bleeding (RR=1.86; 95% CI 1.15 to 3.00; I²=15.3%) compared with IABP treatment (RR=1.86; 95% CI 1.15 to 3.00; I²=15.3%).

CONCLUSIONS

In all patients with AMI undergoing stent implantation, the MCS use does not reduce all-cause mortality. Patients without CS can benefit from MCS regarding long-term survival, while patients with CS seem not.

Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation?

Purpose of Review

We aim to summarize recent insights and provide an up-to-date overview on the role of intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS).

Recent Findings

In the largest randomized controlled trial (RCT) of patients with CS after acute myocardial infarction (AMICS), IABP did not lower mortality. However, recent data suggest a role for IABP in patients who have persistent ischemia after revascularization. Moreover, in the growing population of CS not caused by acute coronary syndrome (ACS), multiple retrospective studies and one small RCT report on significant hemodynamic improvement following (early) initiation of IABP support, which allowed bridging of most patients to recovery or definitive therapies like heart transplant or a left ventricular assist device (LVAD).

Summary

Routine use of IABP in patients with AMICS is not recommended, but many patients with CS either from ischemic or non-ischemic cause may benefit from IABP at least for hemodynamic improvement in the short term. There is a need for a larger RCT regarding the role of IABP in selected patients with ACS, as well as in patients with non-ACS CS.

The Characteristics and Clinical Outcomes of Rotational Atherectomy under Intra-Aortic Balloon Counterpulsation Assistance for Complex and Very High-Risk Coronary Interventions in Contemporary Practice: An Eight-Year Experience from a Tertiary Center

BACKGROUND

The use of Complex and High-risk Coronary Interventions (CHIPs) has increased in recent years. Both rotational atherectomy (RA) and hemodynamic support are important parts of CHIPs.

OBJECTIVES

This study aimed to retrospectively investigate the procedure results and clinical outcomes of intra-aortic balloon pump (IABP)-assisted RA in the contemporary drug-eluting stent era.

METHODS

All consecutive patients who received RA under in-procedure IABP assistance from April 2010 to March 2018 were analyzed retrospectively.

RESULTS

A total of 63 patients (77.7 ± 10.1 years, 69.8% male) were recruited, of whom 51 underwent RA with primary IABP assistance and 12 underwent bailout IABP. RA could be completed in 61 (96.8%) of the patients. Overall, vessel perforation, profound in-procedure shock, and ventricular arrhythmia occurred in 1.6%, 4.8% and 3.2% of the patients, respectively. The in-hospital, 30-day and 90-day major adverse cardiac event (MACE) rates were 22.2%, 27.4% and 36.1%, respectively, mostly driven by mortality. The MACE rates were significantly higher in the bail-out group in the hospital (50.0% vs. 15.7%, p = 0.018) at 30 days (58.3% vs. 20.0%, p = 0.013) and 90 days (66.7% vs. 28.6%, p = 0.020).

CONCLUSIONS

Bail-out IABP was associated with increased MACEs, implying that the use of IABP should be implemented at the beginning of RA if a complex procedure is anticipated.

Successful extracorporeal membrane oxygenation assisted revascularisation in a high-risk elderly patient refused surgical treatment

Management of high-risk elderly patients requiring revascularisation remains a clinical challenge. We report a case of extracorporeal membrane oxygenation (ECMO) assisted complex percutaneous coronary intervention in a  high-risk octogenarian. An 83-year-old female with signs of worsening heart failure was admitted to the emergency department of a tertiary care facility. Transthoracic echocardiography revealed a  decreased left ventricular ejection fraction of 20% with severe mitral regurgitation and mild aortic and tricuspid valve insufficiency. Three-vessel disease was found during coronary angiography. Due to the patient's frailty, a high-risk surgery decision to proceed with ECMO assisted percutaneous coronary intervention was made during a heart team meeting. Following initiation of mechanical support, coronary lesions were treated with three drug-eluting stents. After the procedure, the patient was transferred to the ICU on ECMO support, where she was successfully weaned from the device 9 h later. Her ICU stay was four days. She was successfully discharged from the hospital after uneventful recovery. At one-year's follow-up, the patient was clinically stable in an overall state of general well-being and with complete participation in routine activities; she had good exercise tolerance and no signs of ischemia. This report highlights the possibility of use of ECMO during PCI in high-risk elderly patients.