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Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support.

ABSTRACT: This report describes the case of a 64-year-old man who presented with acute coronary syndrome, depressed left ventricular function, and triple vessel disease on angiogram. The patient refused surgery and underwent high-risk percutaneous coronary intervention through the Impella sheath (Abiomed, Danvers, MA). This is one of the first known cases of single-access protected percutaneous coronary intervention, an innovative technique that brings into consideration the importance of dual vascular access via the Impella sheath.

SUBMITTER: Ahmed T

PROVIDER: S-EPMC7067684 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support.

Ahmed Taha T Lodhi Samra Haroon SH Ahmed Talha T Virk Hafeez Ul Hassan HUH Nukta Emad Dean ED

CJC open 20200120 2

This report describes the case of a 64-year-old man who presented with acute coronary syndrome, depressed left ventricular function, and triple vessel disease on angiogram. The patient refused surgery and underwent high-risk percutaneous coronary intervention through the Impella sheath (Abiomed, Danvers, MA). This is one of the first known cases of single-access protected percutaneous coronary intervention, an innovative technique that brings into consideration the importance of dual vascular ac ...[more]

PMID: 32190830

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Project description:IntroductionHigh-risk percutaneous coronary interventions (HRPCI) are a potential treatment option for patients with reduced left ventricular ejection fraction (LVEF) and coronary artery disease. The extent to which such intervention is coupled with improvement in LVEF and associated with favorable outcomes is unknown.MethodsWe aimed to characterize the incidence and correlates of LVEF improvement after Impella-guided HRPCI, and compare clinical outcomes in patients with versus without LVEF improvement. Data on consecutive patients undergoing Impella-guided HRPCI from a single center registry were analyzed. LVEF-improvement was defined as an absolute increase of LVEF of ≥10% measured at ≥30-days after intervention. The primary outcome was a composite of all-cause death, myocardial infarction or target vessel revascularization within 1-year.ResultsOut of 161 consecutive patients undergoing Impella-guided HRPCI from June 2008 to December 2017, 43% (n = 70) demonstrated LVEF-improvement (baseline LVEF of 25.09 ± 6.19 to 33.30 ± 11.98 post intervention). Patients without LVEF-improvement had higher frequency of previous MI (61.5% vs. 37.1%, p = 0.0021), Q-waves on ECG (17.6% vs. 5.7%, p = 0.024) and higher SYNTAX scores (30.8 ± 17.6 vs. 25.2 ± 12.2; p = 0.043). After correction of these confounders by multivariable analysis, no significant differences were found regarding the composite endpoint in patients with versus without LVEF-improvement (34.9% vs. 38.3%; p = 0.48).DiscussionIn this single-center retrospective analysis, we report the following findings. First, LVEF improvement of at least 10% was documented in over 40% of patients undergoing Impella supported high-risk PCI. Second, a history of MI, Q-waves on admission ECG, and higher baseline SYNTAX scores were independent correlates of no LVEF improvement. Third, one year rates of adverse CV events were substantial and did not vary by the presence or absence of LVEF improvement Prospective studies with longer follow-up are needed to elucidate the impact of LVEF improvement on clinical outcomes.

Project description:Objectives: Several mechanical circulatory assist devices are used to treat critically ill patients requiring hemodynamic support during post-myocardial infarction or cardiogenic shock. However, little guidance is available to choose an appropriate device to match a particular patient's needs. An increased understanding of hemodynamic effects of the pump systems and their impact on myocardial pre-/afterload might help to better understand their behavior in different clinical settings. Methods: This was an open-labeled, randomized acute animal experiment. A model of acute univentricular myocardial injury by temporary balloon occlusion was used. The experiment was carried out in 10 juveniles female Piétrain pigs. The animals were randomized to mechanical hemodynamic support either by peripheral veno-arterial (VA-)ECMO or Impella CP. Results: While both devices were able to provide flows above 3 L/min and maintain sufficient end-organ perfusion, support by Impella resulted in a significantly more pronounced immediate effect on myocardial unloading: At the onset of device support, the remaining native cardiac output was reduced by 23.5 ± 15.3% ECMO vs. 66.2 ± 36.2% (Impella, p = 0.021). Native stroke volume was significantly decreased by Impella support compared to ECMO, indicating less mechanical work being conducted by the Impella-supported hearts despite similar total assisted cardiac output. Conclusions: Peripheral VA-ECMO and the transaortic Impella pump resulted in contrasting hemodynamic fingerprints. Both devices provided sufficient hemodynamic support and reduce left ventricular end-diastolic pressure in the acute setting. Treatment with the Impella device resulted in a more effective volume unloading of the left ventricle. A significant reduction in myocardial oxygen consumption equivalent was achieved by both devices: The Impella device resulted in a left-shift of the pressure-volume loop and a decreased pressure-volume-area (PVA), while VA-ECMO increased PVA but decreased heart rate. These data highlight the importance of specifically targeting heart rate in the management of AMI patients on hemodynamic support.

Dataset Information

Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support.

Publications

Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support.

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