Protected percutaneous coronary intervention with Impella CP in a patient with left main disease, severe left ventricular systolic dysfunction and established hemolysis

Hemolytic anemia after percutaneous coronary intervention (PCI): A case report

Background

In clinical practice, intravascular hemolysis is not common after interventional cardiovascular procedures. Although diagnostic and treatment techniques have developed, with the increasing importance placed on people's own health and the popularity of cardiovascular intervention, there have been occasional reports of hemolysis after different cardiovascular interventions, mainly including cardiac pacemaker implantation, atrial-fibrillation radiofrequency ablation, transcatheter aortic-valve implantation (TAVI), transcatheter mitral valve replacement (TMVR) and percutaneous repair of Gerbode defect and percutaneous coronary intervention (PCI) with Impella. However, so far, there have been no relevant reports on postoperative hemolysis after percutaneous coronary intervention (PCI).

Case report

This article reports a very rare case of a 42-year-old male who developed hemolysis after PCI. The patient had dark brown urine for two days. Blood test showed significant decreases in red blood cell (RBC) and hemoglobin (Hb). After blood transfusion of 2 units, dexamethasone treatment and repeat PCI, he gradually recovered with no symptoms of further episodes of hemolysis.

Conclusions

Due to the use of antiplatelet and anticoagulation drugs in PCI patients, gastrointestinal bleeding (GIB) is often believed to be the main cause of postoperative bleeding events. Identifying the etiology of anemia in patients after PCI is crucial for targeted treatment in the later stage. Based on the symptoms of dark brown urine and the levels of RBC, HB, reticulocyte and unconjugated bilirubin (UCB), we finally diagnosed the patient with hemolytic anemia (HA), rather than the traditional consciousness of GIB. This is an uncommon case of hemolysis after PCI. Although the association between PCI and HA is very rare, PCI is now a commonly used treatment for patients with acute coronary syndromes (ACS). Therefore, clinicians should recognize that in addition to GBI, HA may also occur after PCI. Early recognition of the cause of anemia and early treatment is one of the key steps to ensure the later life and health of PCI patients.

Advances in diagnosis and treatment of mechanical hemolysis following percutaneous interventional for valvular heart diseases

Valvular heart disease is one of the common heart diseases in clinical practice, characterized by valve stenosis and/or incomplete closure. At present, drug therapy, surgery, and emerging percutaneous intervention therapy are the main treating methods for heart valve disease. Although the research and development of percutaneous intervention therapy devices is relatively mature, there are still problems such as postoperative mechanical hemolysis. The occurrence of mechanical hemolysis is associated with factors such as excessive shear stress experienced by red blood cells, direct interaction between red blood cells and the heart and valve surfaces, and thrombus formation. Furthermore, the presence of postoperative infection and other hemolytic diseases can also affect the occurrence of mechanical hemolysis. Although most patients are asymptomatic when hemolysis occurs, there are still critical cases. This type of hemolysis can accelerate the deterioration of the condition, and even endanger life in severe cases. Therefore, elucidating the background, pathogenesis, epidemiology, and related clinical research progress of mechanical hemolysis after percutaneous intervention therapy for valvular heart disease is of great significance for guiding the standardized diagnosis and treatment of the disease.

Contemporary percutaneous management of coronary calcification: current status and future directions

Severe coronary artery calcification is one of the greatest challenges in attaining success in percutaneous coronary intervention, limiting acute and long-term results. In many cases, plaque preparation is a critical prerequisite for delivery of devices across calcific stenoses and also to achieve adequate luminal dimensions. Recent advances in intracoronary imaging and adjunctive technologies now allow the operator to select the most appropriate strategy in each individual case. In this review, we will revisit the distinct advantages of a complete assessment of coronary artery calcification with imaging and application of appropriate and contemporary plaque modification technologies in achieving durable results in this complex lesion subset.

The impact of temporary mechanical circulatory support strategies on thrombocytopenia

One common but not well-understood phenomenon of temporary mechanical circulatory support (MCS) use is thrombocytopenia. This clinical issue increases the risk of bleeding and the need for platelet transfusion. Additionally, heparin-induced thrombocytopenia must be considered as part of the differential diagnosis, which complicates patient management. In what follows, we analyze the degree and relative rate of platelet count drop with various temporary MCS strategies - Impella 5.5; Veno-venous Extracorporeal Membrane Oxygenation (VV ECMO); Veno-arterial ECMO (VA ECMO); Intra-aortic Balloon Pump (IABP) and Centrimag Biventricular Assist Device (BIVAD). A total of 337 cohort was investigated. 77 was included for analysis after strict exclusion criteria were utilized (platelet transfusions, bleeding complications, etc.). Repeated measure mixed effect and linear regression models were used to assess the percent platelet drop on implantation of MCS and recovery after explantation of MCS. A statistically significant mean percent drop occurred in MCS types - VA ECMO(-69.6%, p < 0.001), VV ECMO(-40.9%, p < 0.001), Impella 5.5(-20.9%, p = 0.01) and IABP(-28.3%, p = 0.01), except Centrimag BIVAD(-6.5%, p = 0.61). Platelet recovery to or above baseline occurred in VA ECMO(+107.0%, p = 0.42), Impella 5.5(+117.2%, p = 0.28), IABP(+108.3%, p = 0.37), VV-ECMO(163.3%, p = 0.01*) and Centrimag BIVAD(+100.1%, p = 0.99). These results show that the degree of thrombocytopenia depends on MCS device type and is reversible.

Impella Support as a Bridge to Surgery for Severe Mitral Regurgitation With Cardiogenic Shock

Background: Cardiogenic shock due to acute severe mitral regurgitation is characterized by multiple organ failure and acute pulmonary edema, leading to a high risk of mortality.

Methods and Results: We report on a patient with acute, severe mitral regurgitation complicated by cardiogenic shock, refractory to both inotrope treatment and intra-aortic balloon pump support. The patient was successfully bridged to surgery with an Impella CP, a percutaneous left ventricular assist device.

Conclusions: Mechanical support using an Impella CP can stabilize hemodynamics and may be used as a bridge to elective surgery for patients with mitral regurgitation with cardiogenic shock.

Impella 5.5 Versus Centrimag: A Head-to-Head Comparison of Device Hemocompatibility

Despite growing use of mechanical circulatory support, limitations remain related to hemocompatibility. Here, we performed a head-to-head comparison of the hemocompatibility of a centrifugal cardiac assist system-the Centrimag, with that of the latest generation of an intravascular microaxial system-the Impella 5.5. Specifically, hemolysis, platelet activation, microparticle (MP) generation, and von Willebrand factor (vWF) degradation were evaluated for both devices. Freshly obtained porcine blood was recirculated within device propelled mock loops for 4 hours, and alteration of the hemocompatibility parameters was monitored over time. We found that the Impella 5.5 and Centrimag exhibited low levels of hemolysis, as indicated by minor increase in plasma free hemoglobin. Both devices did not induce platelet degranulation, as no alteration of β-thromboglobulin and P-selectin in plasma occurred, rather minor downregulation of platelet surface P-selectin was detected. Furthermore, blood exposure to shear stress via both Centrimag and Impella 5.5 resulted in a minor decrease of platelet count with associated ejection of procoagulant MPs, and a decrease of vWF functional activity (but not plasma level of vWF-antigen). Greater MP generation was observed with the Centrimag relative to the Impella 5.5. Thus, the Impella 5.5 despite having a lower profile and higher impeller rotational speed demonstrated good and equivalent hemocompatibility, in comparison with the predicate Centrimag, with the advantage of lower generation of MPs.

Impact of the angle between aortic and mitral annulus on the occurrence of hemolysis during Impella support

Despite optimal management, we sometimes experience refractory hemolysis requiring extensive device speed reduction or continuous hemodiafiltration following Impella implantation. However, pre-procedural predictors of such a refractory hemolysis remain unknown. In this study, we investigated the pre-procedural factors, including the echocardiographic narrow angle between aortic and mitral annulus, associating with the occurrence of refractory hemolysis following Impella insertion. We enrolled 26 patients (71 years, 65% male) who received Impella insertion between March 2018 and November 2019. Among baseline characteristics, the angle between aortic and mitral annulus, < 126.5°, was an independent risk factor of refractory hemolysis with an adjusted hazard ratio of 7.840 (95% confidence interval 0.925-66.44) and was associated with lower 30-day survival (64% vs. 100%, p = 0.0116). The narrow angle between aortic and mitral annulus might be a useful tool to risk-stratify the occurrence of refractory hemolysis following Impella insertion.