scholarly journals Mechanical circulatory-support and intravascular lithotripsy in high-risk patients undergoing PCI and TAVR: a case series

2021 ◽  
Author(s):  
Alfredo Marchese ◽  
Giuseppe Tarantini ◽  
Antonio Tito ◽  
Vito Margari ◽  
Fabrizio Resta ◽  
...  
Keyword(s):  
High Risk ◽  
Mechanical Circulatory Support ◽  
Case Series ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Transcatheter Aortic Valve ◽  
Clinical Scenarios ◽  
Risk Patients ◽  
Coronary Lesions ◽  
Va Ecmo

Abstract Background Patients undergoing transcatheter aortic-valve replacement (TAVR) usually have multiple comorbidities, such as severely impaired left-ventricular function (LVF) and heavily calcified coronary lesions. When they undergo pre-TAVR high-risk percutaneous coronary interventions (HR-PCIs) for severely calcified left-main (LM) lesions, potential life-threatening intra-procedural complications associated with the different techniques available to treat calcified lesions can arise. In this setting, mechanical circulatory support (MCS) proves its usefulness. However, the choice of device can be troublesome. Case summary We report two clinical scenarios of intravascular lithotripsy (IVL) for the treatment of heavily calcified LM coronary lesions, wherein peripheral veno-arterial extracorporeal-membrane oxygenation (VA-ECMO), alone or combined with an intra-aortic balloon pump (IABP), were used as an upfront strategy to support the procedure. The use of these techniques was particularly effective during multi-vessel HR-PCIs and TAVR, and no complications occurred, which suggested their safety. Discussion These cases provide multiple insights into the strategy of using IVL + VA-ECMO, alone or with IABP, to treat heavily calcified LM coronary lesions in patients with severely compromised LVF undergoing TAVR. IVL safely and effectively overcame shortcomings related to other plaque ablation techniques, and VA-ECMO proved to be effective when facing the combination of high-risk coronary and valve interventions.

scholarly journals Incidence of Acute Kidney Injury Is Lower in High-Risk Patients Undergoing Percutaneous Coronary Intervention Supported with Impella Compared to ECMO

2021 ◽  
Author(s):  
Julian Schweitzer ◽  
Patrick Horn ◽  
Fabian Voss ◽  
Milena Kivel ◽  
Georg Wolff ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
High Risk ◽  
Mechanical Circulatory Support ◽  
Kidney Injury ◽  
Coronary Intervention ◽  
Circulatory Support ◽  
Risk Allocation ◽  
Percutaneous Coronary ◽  
Risk Patients ◽  
Va Ecmo

AbstractAcute kidney injury (AKI) is a common complication post-PCI. Here, in a single-center observational registry, we compared the frequency of AKI in patients at elevated risk for AKI (based on Mehran risk stratification scoring) who underwent VA-ECMO- or Impella-supported high-risk PCI. A total of 28 patients scheduled for elective high-risk PCI with mechanical circulatory support were studied prospectively. All patients were turned down for surgery due to exceedingly high risk. Allocation to VA-ECMO (n=11) or Impella (n=17) was performed according to site-specific restrictions on the daily availability of the VA-ECMO platform as a prospective enrollment and performed prior to initiation of PCI. We analyzed AKI incidence as our primary endpoint, as well as PCI success, duration, and peripheral complications. All patients were successfully revascularized and had MCS weaned at the end of the procedure. Baseline GFR and procedural contrast media were similar. Despite similar risks for AKI as calculated by the Mehran score (35 ± 18.9 vs. 31 ± 16.6 %; p=0.55), patients supported by Impella during PCI demonstrated a reduced incidence of AKI (55 vs. 12 %; p=0.03). MCS-assisted high-risk PCI with VA-ECMO or Impella is feasible. However, Impella is associated with a shorter procedure time and a lower incidence of AKI.

Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock

Perfusion ◽  
2021 ◽  
pp. 026765912110339
Author(s):  
Shek-yin Au ◽  
Ka-man Fong ◽  
Chun-Fung Sunny Tsang ◽  
Ka-Chun Alan Chan ◽  
Chi Yuen Wong ◽  
...  
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Mechanical Circulatory Support ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Queen Elizabeth Hospital ◽  
Intra Aortic Balloon Pump ◽  
Membrane Oxygenation ◽  
Significant Difference ◽  
Va Ecmo

Introduction: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. Methods: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. Results: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. Conclusions: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

scholarly journals Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Ryan Ruiyang Ling ◽  
Kollengode Ramanathan ◽  
Wynne Hsing Poon ◽  
Chuen Seng Tan ◽  
Nicolas Brechot ◽  
...  
Keyword(s):  
Septic Shock ◽  
Extracorporeal Membrane Oxygenation ◽  
Mechanical Circulatory Support ◽  
Meta Analysis ◽  
Left Ventricular ◽  
Adult Patients ◽  
Circulatory Support ◽  
Venoarterial Extracorporeal Membrane Oxygenation ◽  
Refractory Septic Shock ◽  
Va Ecmo

Abstract Background While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival. Methods We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%–50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%–72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%–60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%–26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%–73.0%) and North America (45.5%, 95%-CI: 16.7%–75.8%). GRADE assessment indicated high certainty of evidence for pooled survival. Conclusions When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

Abstract 13425: Comparison Between Impella 5.0 and External Corporeal Left Ventricular Assist Device as a Bridge to Decision in Patients With Cardiogenic Shock

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Toru Kondo ◽  
Naoki Shibata ◽  
shingo kazama ◽  
Yuki Kimura ◽  
Hideo Oishi ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Assist Device ◽  
Ventricular Assist ◽  
Cardiac Recovery ◽  
Left Ventricular Assist ◽  
Bridge To Decision ◽  
Va Ecmo

Background: In cardiogenic shock refractory to medical treatment, choosing and changing mechanical circulatory support to stabilize hemodynamics until cardiac recovery or next treatment is a strategic cornerstone for improving the outcome. We aimed to clarify the differences in treatment course and outcome between Impella 5.0 and extracorporeal left ventricular assist device (eLVAD) in patients with cardiogenic shock refractory to medical therapy or other mechanical circulatory support. Methods: We performed a retrospective medical record review of consecutive patients who were treated with Impella 5.0 or eLVAD as a bridge to decision (BTD) at our medical center from December 2011 to January 2020. Results: A total of 26 patients (median age 40 years, 16 males) were analyzed. Of seven patients managed with Impella 5.0, one patients used Impella CP and four patients used peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) before Impella 5.0 implantation. On the other hand, of 19 patients managed with eLVAD, 11 patients used VA-ECMO before eLVAD implantation. In patients managed with Impella 5.0, Impella 5.0 was removed successfully in two patients (29%) and four patients (71%) underwent the operation for durable LVAD. In patients managed with eLVAD, eLVAD was successfully removed in three patients (16%), nine patients (47%) required durable LVAD, and seven patients (37%) died during eLVAD management. The period between implantation of Impella 5.0 or eLVAD to durable LVAD surgery was significantly shorter with Impella 5.0 (58 [38 - 95] vs. 235 [126 - 318] days, p=0.001). During durable LVAD implantation, cardiopulmonary bypass time was significantly shorter and a significantly smaller amount of red blood cells transfusion was required with Impella 5.0 (149 [125 - 182] vs. 192 [170 - 250] minutes, p=0.042; 7.0 [5.0 - 9.5] vs. 15.0 [10.0- 2.0] units, p=0.019, respectively). There were 4 massive stroke events in eLVAD, but no massive stroke events in Impella 5.0. In Impella 5.0. Conclusions: Impella 5.0 facilitates smoother management as a BTD and reduces surgical invasiveness during durable LVAD implantation. Impella 5.0 would be a more effective option for success to cardiac recovery or next therapy than eLVAD.

Neuroprotection for Mechanical Circulatory Support

2017 ◽  
Author(s):  
Lauren E Dunn ◽  
Joshua Z Willey ◽  
Ronald M Lazar
Keyword(s):  
Mechanical Circulatory Support ◽  
Management Strategies ◽  
Air Embolism ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Left Ventricular Assist Devices ◽  
Cerebral Air Embolism ◽  
Cerebral Hyperperfusion ◽  
Clinical Scenarios

This chapter examines the adverse neurological events associated with mechanical circulatory support (MCS), which includes left ventricular assist devices (LVAD) and percutaneous devices for cardiac disease. The most frequently encountered neurological events are ischemic and hemorrhagic stroke, as well as intracerebral hemorrhage (ICH), heart failure and cardiovascular disease. The management of acute cerebrovascular conditions in this population poses unique challenges, given concomitant anticoagulation usage, hemodynamically unstable patients, and lack of randomized controlled trials investigating these clinical scenarios. Other acute neurological events include cerebral hyperperfusion and cerebral air embolism. This chapter describes these complications and their risk factors, and the available evidence-based and institutional management strategies.

scholarly journals Complex cardiac surgery in a high-risk patient with new-onset severe mitral regurgitation and aorta to right ventricular fistula after transcatheter aortic valve implantation: a case report

2020 ◽  
Vol 4 (5) ◽  
pp. 1-5
Author(s):  
Mario Verdugo-Marchese ◽  
Pierre Monney ◽  
Olivier Muller ◽  
Matthias Kirsch
Keyword(s):  
Heart Failure ◽  
Cardiac Surgery ◽  
High Risk ◽  
Aortic Valve ◽  
Right Ventricular ◽  
Left Ventricular ◽  
Transcatheter Aortic Valve ◽  
Risk Patients ◽  
Aortic Valve Implantation ◽  
Valve Implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) is the procedure of choice for aortic stenosis in high surgical risk patients, but it is no free from complications. Case summary A 86-year-old patient with severe aortic stenosis underwent TAVI 3 years ago with an Edwards Sapiens valve by femoral access. In the echocardiography follow-up, an aorta–right ventricular (Ao-RV) fistula was noted with restrictive flow and no significant shunt and it was treated conservatively. Three years after TAVI, the patient underwent cardiac surgery because of worsening heart failure due to a severe degenerative mitral regurgitation with tethering of P2 due to left ventricular remodelling, a posterior jet of severe regurgitation, and left ventricular dilatation. Surgical replacement of the TAVI and aortic root with a bioprosthesis (Medtronic Freestyle) and direct closure of the fistula was performed along with the mitral valve replacement. The patient was discharged with a good clinical result and no evidence of remaining Ao-RV fistula at transthoracic echocardiography. Discussion Aorta–right ventricular fistula is a rare entity. Most reported cases arise after rupture of a congenital coronary sinus aneurism, endocarditis, trauma, and aortic valve or aortic root surgery. This is the 10th reported case after TAVI (9 after an Edwards Sapiens TAVI). Non-significant shunt can be treated conservatively but development of heart failure and death are described in significant shunts. Balloon post-dilatation and the absence of surgical calcium debridement inherent to TAVI may theoretically contribute to the development of the fistula. Surgical replacement and closure of the fistula is a therapeutic option for this entity even in high-risk patients.

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