Unprotected left main percutaneous coronary intervention in acute coronary syndromes with extracorporeal life support backup

Cardiac intensive care management of high-risk percutaneous coronary intervention using the venoarterial ECMO support

The emerging concept of high-risk percutaneous coronary intervention (HR-PCI) has required the adoption of a multidisciplinary team approach. Venoarterial ECMO (VA-ECMO) has been introduced as a temporary mechanical circulatory support (MCS) for HR-PCI patients in order to provide an adequate systemic perfusion during the procedure. Both patient's complexity and technological evolutions have catalyzed the development of critical care cardiology; however, ECMO therapy faces several challenges. Indeed, the management of patients on ECMO remains complex; moreover, the lack of specific recommendation for HR-PCI patients further complicates the management of these patients. In this narrative review, we give a reappraisal for the management of HR-PCI patients supported with VA-ECMO according to the available data published in current literature.

Venoarterial extracorporeal membrane oxygenation decannulation using the novel Manta vascular closure device

Aims:

Removal of large calibre arterial sheaths, as employed in venoarterial extracorporeal membrane oxygenation, is still associated with a high risk for vascular access site complications. In this study, we investigated the large bore Manta closure device as an option for venoarterial extracorporeal membrane oxygenation decannulation.

Methods and results:

Sixteen patients weaned from venoarterial extracorporeal membrane oxygenation between January–June 2019 were prospectively included in a registry (eight during extracorporeal cardiopulmonary resuscitation, seven with severe cardiogenic shock and one patient with fulminant pulmonary embolism). All patients had an arterial sheath removed at bedside using the Manta device achieving rapid haemostasis without clinically relevant complications afterwards. A computed tomography angiography was available for 11 patients (68.8%) and reassessed with regards to relevant pathologies at the closure device. Average intraluminal area was 40.4 mm2 (12.2–76.3 mm2) at the closure site. All devices but one were correctly deployed. Three patients (27.3%) had a visible thrombus at the closure device resulting in a >60% stenosis, two of which had a puncture site distal of the femoral artery bifurcation.

Conclusion:

Decannulation from venoarterial extracorporeal membrane oxygenation using the Manta closure device is a viable approach for rapid haemostasis, but is also associated with a significant risk of thrombotic vessel stenosis. These preliminary findings indicate that puncture in near proximity or distal to the femoral bifurcation might identify patients at risk and further studies are needed.

Dual Antiplatelet Therapy (DAPT) versus No Antiplatelet Therapy and Incidence of Major Bleeding in Patients on Venoarterial Extracorporeal Membrane Oxygenation

Aims

Bleeding is a frequent complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). An indication for dual antiplatelet therapy due to coronary stent implantation is present in a considerable number of these patients. The objective of this retrospective study was to evaluate if dual antiplatelet therapy (DAPT) significantly increases the high intrinsic bleeding risk in patients on VA-ECMO.

Methods and Results

A total of 93 patients were treated with VA-ECMO between October 2010 and October 2013. Average time on VA-ECMO was 58.9 ± 1.7 hours. Dual antiplatelet therapy was given to 51.6% of all patients. Any bleeding was recorded in 60.2% of all patients. There was no difference in bleeding incidence in patients on DAPT when compared to those without any antiplatelet therapy including any bleeding (66.7% vs. 57.1%, p = 0.35), BARC3 bleeding (43.8% vs. 33.3%, p = 0.31) or pulmonary bleeding (16.7% vs. 19.0%, p = 0.77). This holds true after adjustment for confounders. Rate of transfusion of red blood cells were similar in patients with or without DAPT (35.4% vs. 28.6%, p = 0.488).

Conclusions

Bleeding on VA-ECMO is frequent. This registry recorded no statistical difference in bleeding in patients on dual antiplatelet therapy when compared to no antiplatelet therapy. When indicated, DAPT should not be withheld from VA ECMO patients.