Left Ventricular Support Systems for High-Risk Percutaneous Coronary Interventions

Abstract

High-risk percutaneous coronary interventions (PCI) are becoming more prevalent as the ability to perform complex coronary interventions continues to improve. Patients for whom high-risk interventions are considered generally have severe diffuse coronary artery disease, a single last patent conduit, or significant left main disease with large territories of myocardial ischemia. In addition, these patients also typically have reduced left ventricular function (ejection fraction <25%–35%) with comorbidities that make them high risk for standard coronary artery bypass grafting. Thus, PCI is increasingly used as a viable alternative for coronary revascularization, but it too is associated with a high degree of morbidity and mortality. Article see p 207 Coronary ischemia can transiently worsen during PCI through repeated balloon inflations, stent manipulations, and contrast injections that result in a negative inotropic effect.1 In patients with left ventricular dysfunction and large territories of ischemia who have little reserve, this can lead to reductions in blood pressure that make it hard to complete the revascularization. Hemodynamic support during the conduct of the PCI, such as that provided by intra-aortic balloon pump (IABP) counterpulsation or Impella, may therefore maintain perfusion pressure throughout the procedure to reduce the risk associated with these complex interventions. Kahn and colleagues reported the first use of intra-aortic balloon pumps to support high-risk PCI in 1990 among 28 patients with severe LV dysfunction undergoing PCI for 3-vessel or left main coronary artery disease.2 This study established that IABP support in this setting was safe and allowed the PCI to be completed without untoward risk. IABP use for this indication has continued to grow since that time and now is one of the more common reasons for IABP use in the cardiac catheterization laboratory, reflective of the growing number of high-risk PCIs being performed by interventional cardiologists.3 In an analysis …