Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients' condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01-18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.

Intravascular imaging to guide lithotripsy in concentric and eccentric calcific coronary lesions

Background

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

Purpose

The study aimed at the evaluation of the immediate procedural outcome of a novel treatment algorithm based on IVUS and/or OCT and including lithotripsy into a real-world consecutive based on intravascular imaging assessment by IVUS or OCT.

Methods and results

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions in 370 patients treated between November 2018 and May 2019 met the clinical and angiographic criteria for treatment with IVL under intravascular imaging guidance. Patients were divided into two subgroups depending on the calcium arc measured with intravascular imaging. Twenty lesions showed a calcium arc greater than 180 degrees (289±53 degrees) and 11 lesions smaller than 180 (140±24 degrees). The following parameters were assessed with OCT and/or IVUS: post stent minimal lumen area (MLA) and area stenosis (AS), incomplete strut apposition (ISA), eccentricity index, strut fracture, and edge dissection. After optimization a satisfactory lumen enlargement (acute gain 1.28±0.46 mm; minimal stent area 7.09±2.77 mm2) was observed with good stent expansion (residual area stenosis <20% in 29 lesions, 93.5%) and OCT calcium fractures in 71% of cases. Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no in-hospital coronary perforations, no pericardial effusions, no stent failure or thrombosis, no deaths.

Conclusions

A standardized algorithm applying multimodality imaging to guide selection and application of IVL facilitated second generation DES implantation with final post-dilatation delivers excellent immediate procedural results and patient outcome, both in concentric or eccentric calcifications.

Funding Acknowledgement

Type of funding source: None

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions

BACKGROUND

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

PURPOSE

The study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT.

METHODS AND RESULTS

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ± 2.77 mm²) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis. When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ± 24°; Group B: 21 lesions, calcium arc 289 ± 53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ± 0.29 mm; group B: 1.31 ± 0.52 mm, p = 0.63).

CONCLUSIONS

A standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.