Abstract 18607: High-Risk, Multi-Vessel Coronary Intervention Guided by Viability-Imaging and Supported by Awake-ECMO in Patients With Severe Ischemic Cardiomyopathy is Feasible, Safe, and Efficacious

Abstract

Background: The burden of end-stage coronary artery disease is rising and its care is complicated by cardiac failure and hospitalization. Recruitment of ischemic but viable myocardium is warranted to balance risk and benefit. Mechanical support enables high-risk coronary interventions despite severe LV-dysfunction. We aimed to develop a therapeutic algorithm of viability guided, awake-ECMO supported revascularization to stabilize therapy-refractory patients. Methods/Results: In this single-center study, consecutive patients (n=5, 61±9 yrs, all male) were prospectively enrolled (baseline: EF/echo study 15±4%; EF/SPECT-CT 17±5%). Myocardial perfusion SPECT-CT and viability 18-fluordesoxy-glucose (FDG)-PET imaging was performed. Veno-arterial ECMO (rate 3050±495 rpm, flow 2.8±1.0 l/min) was inserted in awake patients. Targeted by viability pattern, complex interventional revascularization was performed (2.8±1.1 vessels/patient, 3.0±1.5 stents/patient) without complications. Because no procedure/ECMO-related complications occurred, patients were discharged 5-7 days after PCI. During follow-up cardiac function improved significantly (ΔBNP: -42±15 %, p=ns; EF/echo: follow-up 26±7 %, ΔEF +11±7% vs. baseline, p<0.05; EF/SPECT-CT 29±7%, ΔEF +11±6% vs. baseline, p<0.05). This observation was associated with a clinical improvement (NYHA: 2.2±0.8; 6-minute walk: 242±76m; workload: max. 69±24W, VO 2 max. 9±2 ml/(min*kg), O 2 -pulse 8±2 ml/beat). Reflecting the recruitment of hibernating myocardium, perfusion defect score (SRS) was 27±15, LV-perfusion/metabolism mismatch 37±15%, and extent of scar 20±25%. Following revascularization, the perfusion defect score decreased (SRS: follow-up 21±14, p<0.05); 50 of 85 myocardial segments showed significant improvement. All patient reported freedom from acute events for 172±61 days. Conclusion: We developed a novel algorithm of high-risk, multi-vessel coronary intervention guided by perfusion/viability-imaging and supported by transient awake-ECMO in fragile patients. This interdisciplinary strategy was safe, feasible, and efficacious in recruiting hibernating myocardium, and improving formerly unstable patients.