Case Report: Key Role of the Impella Device to Achieve Complete Revascularization in a Patient With Complex Multivessel Disease and Severely Depressed Left Ventricular Function

Background: Left ventricle (LV) assist devices may be required to stabilize hemodynamic status during complex, high-risk, and indicated procedures (CHIP). We present a case in which elective hemodynamic support with the Impella CP device was essential to achieve complete revascularization with PCI in a patient with complex multivessel disease and severely depressed LV function.Case Summary: A 45-year-old male with no previous history of cardiovascular disease presented to the emergency department for new onset exertional dyspnoea. Echocardiography showed severely depressed LV function (EF 27%) that was confirmed with cardiac magnetic resonance. Two chronic total occlusions (CTOs) of the proximal right coronary artery (RCA) and left circumflex coronary artery (LCx) were found at coronary angiography. After Heart Team evaluation, PCI with Impella hemodynamic support was planned. After crossing and predilating the CTO of the LCx, ventricular fibrillation (VF) occurred. No direct current (DC) shock was performed because the patient was conscious thanks to the support provided by the Impella pump. About 1 min later, spontaneous termination of VF occurred. Afterwards, the two CTOs were successfully treated with good result and no complications. Recovery of LV function was observed at discharge. At 9 months, the patient had no symptoms and echocardiography showed an EF of 60%.Discussion: In this complex high-risk patient, hemodynamic support was essential to allow successful PCI. It is remarkable that the patient remained conscious and hemodynamically stable during VF that spontaneously terminated after 1 min, likely because the Impella pump provided preserved coronary perfusion and LV unloading. This case confirms the pivotal role of Impella in supporting CHIP, particularly in patients with multivessel disease and depressed LV function.

Sedation versus General Anesthesia for Cardiac Catheterization in Infants: A Retrospective, Monocentric, Cohort Evaluation

Background: Children with congenital heart disease require repeated catheterization. Anesthetic management influences the procedure and may influence outcome; however, data and recommendations are lacking for infants. We studied the influence of sedation versus general anesthesia (GA) on adverse events during catheterization for children <2 years old. Methods: We conducted a monocentric, retrospective study of all catheterization procedures (2008–2013). High-severity adverse event (HSAE) rates were compared using propensity-score-adjusted models, including pre- and intra-procedural variables. Results: 803 cases (619 patients) (368 (46%) GA, 435 (54%) sedation) with a mean age of 6.9 ± 6.1 months were studied. The conversion rate (GA after sedation) was 18 (4%). Hospital stay was 4.9 ± 4.0 and 4.1 ± 2.5 (p = 0.01) after GA or sedation, respectively. HSAE occurred in 75 (20%) versus 40 (9%) (p < 0.01) in GA versus sedation procedures, respectively. Risk factors (multivariable analysis) were older patients (p = 0.05), smaller weights (p < 0.01), palliated status (OR 3.2 [1.2–8.9], p = 0.02), two-ventricle physiology (OR 7.3 [2.7–20.2], p < 0.01), cyanosis (OR 4.6 [2.2–9.8], p < 0.01), pulmonary hypertension (OR 5.6 [2.0–15.5], p < 0.01), interventional catheterization (OR 1.8 [1.1–3.2], p = 0.02) and procedure-type risk category 4 (OR 28.9 [1.8–455.1], p = 0.02). Sedation did not increase the events rate and decreased the requirement for hemodynamic support (OR 5.2 [2.2–12.0], p < 0.01). Conclusion: Sedation versus GA for cardiac catheterization in children <2 years old is safe and effective with regard to HSAE. Sedation also decreases the requirement for hemodynamic support. Paradoxical effects (older age and two-ventricle physiology) on risk have been found for this specific age cluster.

Current Landscape of Temporary Percutaneous Mechanical Circulatory Support Technology

Mechanical circulatory support devices provide hemodynamic support to patients who present with cardiogenic shock. These devices work using different mechanisms to provide univentricular or biventricular support. There is a growing body of evidence supporting use of these devices as a goal for cardiac recovery or as a bridge to definitive therapy, but definitive, well-powered studies are still needed. Mechanical circulatory support devices are increasingly used using shock team and protocols, which can help clinicians in decision making, balancing operator and institutional experience and expertise. The aim of this article is to review commercially available mechanical circulatory support devices, their profiles and mechanisms of action, and the evidence available regarding their use.

Outcome of Impella 2.5 use in patients undergoing Percutaneous Coronary Intervention in Henan, China: a case series

Background: Acute myocardial infarction (AMI) complicated by cardiogenic shock (AMI-CS) or heart failure is associated with an unacceptably high in-hospital mortality of 33%–55% and a lost chance to accept PCI (Percutaneous Coronary Intervention). Aim: The aim of the study was to find out whether percutaneous hemodynamic support device Impella 2.5 improves prognosis of high-risk PCI patients or not. Methods: This study was a case series involving six patients who underwent a Left Ventricular Assist Device (LVAD, Impella 2.5, Abiomed, Danvers, MA) implantation after suffering from AMI with a very low ejection fraction and acute heart failure. The clinical experience and outcomes of the patients are hereby discussed. Results: All PCI procedures were safely completed under LVAD support. The hemodynamic parameters of all patients improved clinically over the next 30 days and following 12 months after Impella insertion except in two patients, of which one patient (Case number 6) died 4 days post-Impella protected PCI procedure due to acute left ventricle heart failure with cardiogenic shock and pulmonary oedema; and another one died at 12 months after Impella protected PCI procedure (Case number 4) due to decompensated heart failure and infected pneumonia. Conclusion: Percutaneous hemodynamic support is favorable and feasible during high risk Percutaneous Coronary Intervention (PCI). A bigger study is needed to substantiate the claims of the current study.

Venoarterio-Venous (VA-V) ECMO Configuration: A Single-Center Experience

Patients in respiratory failure on VV ECMO may develop cardiovascular dysfunction necessitating additional hemodynamic support, while patients in cardiovascular failure on VA ECMO may require additional respiratory support for concurrent gas exchange abnormalities. A hybrid venoarterio-venous (VA-V) configuration provides both cardiac support via a traditional arterial reinfusion cannula and respiratory support via an additional venous reinfusion limb. We describe our single center experience using VA-V ECMO for patients (n = 14, median age 54) with combined cardiopulmonary failure or differential hypoxemia. Patients were treated with ECMO support for a median of 148.2 (IQR 122.6 – 174.4) hours, consisting of 0 (IQR 0 – 1.8) hours of VA and 92.4 (IQR 58 – 115) hours of VA-V followed by 46 (IQR 0 – 95.5) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%).

ECMO after cardiac surgery: a single center study on survival and optimizing outcomes

Background The study purpose is to examine survival prognostic and extracorporeal membrane oxygenation (ECMO) application outcomes at our tertiary care center. Methods This is a retrospective analysis, January 2014 to September 2019. We analyzed 60 patients who underwent cardiac surgery and required peri-operative ECMO. All inpatients with demographic and intervention data was examined. 52 patients (86.6%) had refractory cardiogenic shock, 7 patients (11.6%) had pulmonary insufficiency, and 1 patient (1.6%) had hemorrhagic shock, all patients required either venous-arterial (VA) (n = 53, 88.3%), venous-venous (VV) (n = 5, 8.3%) or venous-arterial-venous (VAV) (n = 2, 3.3%) ECMO for hemodynamic support. ECMO parameters were analyzed and common postoperative complications were examined in the setting of survival with comorbidities. Results In-hospital mortality was 60.7% (n = 37). Patients who survived were younger (52 ± 3.3 vs 66 ± 1.5, p < 0.001) with longer hospital stays (35 ± 4.0 vs 20 ± 1.5, p < 0.03). Survivors required fewer blood products (13 ± 2.3 vs 25 ± 2.3, p = 0.02) with a net negative fluid balance (− 3.5 ± 1.6 vs 3.4 ± 1.6, p = 0.01). Cardiac re-operations worsened survival. Conclusion ECMO is a viable rescue strategy for cardiac surgery patients with a 40% survival to discharge rate. Careful attention to volume management and blood transfusion are important markers for potential survival.

Hemodynamic Monitoring in Sepsis—A Conceptual Framework of Macro- and Microcirculatory Alterations

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.

An anthropogenic model of cardiovascular system adaptation to the Earth’s gravity as the conceptual basis of pathological anthropology

Applying human biological evolution to solve topical problems of medicine and preventive cardiology was inspired by the realization of the need for clinical and experimental studies of biological (evolutionary) prerequisites in the occurrence of a pathology. Although it has been stated that there is a need to provide a full biological understanding of features, including those that increase an animal’s vulnerability to diseases, unfortunately, in this regard, erectile and associated adaptations to the Earth’s gravity in their physiological and pathological manifestations have not been considered. At the same time, it should be noted that humans, unlike other animal species, have the greatest vulnerability of the cardiovascular system (CVS). The latter is associated with fundamental differences in the functioning and regulation of the CVS by the influence of gravity on blood circulation in humans as upright creatures. Based on a review of comparative physiological, ontogenetic, and clinical studies from an evolutionary perspective, the idea of adaptation to the Earth’s gravity when walking upright in humans is justified as an anthropogenic basis for the physiology and pathology of the cardiovascular system and hemodynamic support systems (physio-anthropology and pathological anthropology).

Cholinesterase activity in serum during general anesthesia in patients with or without vascular disease

Maintaining hemodynamic stability during the induction and maintenance of anesthesia is one of the challenges of the anesthesiologist. Patients with vascular disease are at increased risk of instability due to imbalance between the sympathetic and parasympathetic parts of the autonomic nervous system, a balance accessible by serum cholinesterase activity. We aim to characterize the dynamics of cholinesterase activity in patients undergoing general anesthesia (GA) and surgery. This was a prospective study of 57 patients undergoing ambulatory or vascular surgery under GA. Cholinesterase activity was measured before the induction of anesthesia, after 15 min and at the end of surgery by calculating the capacity of serum acetylcholinesterase (AChE) and butyrylcholinesterase to hydrolyze AcetylThioCholine. Data on atherosclerotic disease, anesthesia management were analyzed. Both AChE and total cholinergic status (CS) decreased significantly after GA induction at 15 min and even more so by the end of surgery. Vascular surgery patients had lower baseline cholinesterase activity compared to ambulatory surgery patients. Patients requiring intraoperative administration of phenylephrine for hemodynamic support (21.1%) had a significantly lower level of AChE and CS compared to untreated patients. Our findings serve as a mirror to the sympathetic/parasympathetic imbalance during GA, with a marked decrease in the parasympathetic tone. The data of a subgroup analysis show a correlation between low cholinesterase activity and an increase in the need for hemodynamic support.