High-risk Coronary Intervention Research Articles

Acute Occlusion of a “Protected” Left Main Coronary Artery Manifesting as an Acute Coronary Syndrome with Heart Failure: How much Protected it is?

Despite the progress made in technological advancements, the utilization of stenting for both protected and unprotected left main coronary artery (LMCA) disease remains associated with elevated rates of long-term mortality and significant adverse clinical events, sometimes manifesting as cardiogenic shock. A considerable number of individuals retain the opportunity to receive catheter-based interventional therapy as a viable substitute for re-operative coronary artery bypass grafting (CABG). Despite the changed appearance, patients with acute blockage of the protected LMCA still have major adverse cardiac events (MACE) at a similar rate. Acute occlusion of the unprotected LMCA as an acute coronary syndrome (ACS) is uncommon, but that of the protected LMCA is relatively rare. We present a case of a post-CABG patient who developed ACS as a posterior wall myocardial infarction and acute left ventricular failure due to obstruction of a protected LMCA with substantial stenosis across its distal segment extending to the left circumflex (LCx) artery. The pharmaco-invasive management of the protected LMCA thrombotic occlusion with primary percutaneous coronary intervention resulted in significant patient improvement. These lesions are amenable to complex and high-risk coronary intervention with current technology, and the results have been quite encouraging in terms of long-term survival.

Abstract 14961: Revitalizing Graft Patency: Intravascular Lithotripsy in Calcified Saphenous Vein Graft to Left Anterior Descending Artery Stenosis

A 73-year-old man with coronary artery disease (CAD), coronary artery bypass graft, heart failure [EF 25%] & hypertension presented with Non-ST Segment Myocardial Infarction. Angiography revealed multivessel CAD with chronic total occlusion (CTO) of mid-left anterior descending (LAD) after a large first diagonal branch, CTO of mid-left circumflex & distal right coronary artery. Saphenous vein graft (SVG) to obtuse marginal was patent. SVG-diagonal & SVG-ramus intermedius were occluded. Mid SVG-LAD showed severe calcified stenosis (Fig. 1A). Native LAD beyond the SVG provided left to right collaterals to right posterior descending artery. Complex high-risk coronary intervention was performed on the SVG-LAD with mechanical circulatory support (MCS; Impella CP). SVG-LAD had a balloon undilatable lesion despite high pressure inflation with 4.0 mm cutting balloon (Fig. 1B). Intravascular ultrasound (IVUS) revealed severe stenosis with extensive circumferential calcification (Fig. 1C). Subsequently, intravascular lithotripsy (IVL) with 4.0 mm Shockwave balloon followed by high pressure balloon angioplasty with 4.5 mm noncompliant (NC) balloon was performed with significant luminal gain and fractures in calcium (Fig. 1D). The lesion was treated with 5.0 mm drug eluting stents that were post dilated with 5.0 mm NC balloon with excellent angiographic and IVUS result (Figs. 1E & F). MCS was successfully removed at the end of the case.SVG grafts are associated with poor long-term patency compared to arterial grafts. PCI to SVG has a high failure rate and PCI of native vessel is often preferable. High risk SVG interventions with atherectomy have been recently reported, though data is limited. IVL has been safely used in heavily calcified native coronary arteries, however, its use in SVG disease is rare. We report the first off-label use IVL of SVG-LAD with MCS for treatment of a last-remaining conduit. Additional studies to assess IVL efficacy in vein grafts are warranted.

Roadmap towards an institutional Impella programme for high-risk coronary interventions.

Coronary artery disease (CAD) and its complications remain the main cause of morbidity and mortality worldwide. Patients with extensive CAD and multiple comorbidities who require complex, high-risk percutaneous coronary intervention (HR-PCI) are at risk of haemodynamic instability and may require short-term mechanical circulatory support (MCS) during the procedure to maintain sufficient perfusion and prevent ischaemia. Impella is a microaxial continuous blood flow pump used for percutaneous support of the left ventricle in patients undergoing HR-PCI. Data from randomized controlled trials and registries suggested an advantage for Impella devices in patients undergoing HR-PCI, compared with other types of MCS. As a thorough understanding of the benefits and drawbacks of the Impella technology is crucial for patient outcomes, we provide a technological overview of Impella and share our experiences gathered during the implementation of institutional Impella programmes in Poland as a roadmap of selection and periprocedural care for patients treated with Impella in the setting of HR-PCI. We propose 10 steps for implementation of an institutional Impella programme for HR-PCI, including (i) dedicated staff training; (ii) standard operating procedure and troubleshooting algorithms prior to the first intervention; (iii) patient selection by the multidisciplinary Heart Team; (iv) patient preparation using multimodality imaging; (v) procedure planning in terms of large-bore access, equipment, and complete revascularization; (vi) starting with HR-PCI support; (vii) starting with femoral artery access in a patient without extensive peripheral artery disease; (viii) multidisciplinary care after the procedure; (ix) haemodynamic and laboratory monitoring to ensure immediate diagnosis of access-site complications, bleeding, haemolysis, acute kidney injury, and infections; and (x) careful revision of every HR-PCI case with the team.

Prophylactic ECMO Support during Elective Coronary Percutaneous Interventions in High-Risk Patients: A Single-Center Experience.

Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions. This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success. Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis. Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery.

European best practice: a step forward to optimize Impella-protected percutaneous coronary intervention to improve outcome after high-risk coronary interventions.

European best practice: a step forward to optimize Impella-protected percutaneous coronary intervention to improve outcome after high-risk coronary interventions.

Combined Pharmacological and Complex and High-risk Coronary Intervention of Chronic Total Occlusion for Ischemic Mitral Regurgitation

Percutaneous coronary intervention for chronic total occlusion is a complex and high-risk intervention (CHIP). Even though persistent ischemia-induced mitral regurgitation is rare, ischemic mitral regurgitation is a frequent complication of an acute coronary crisis. Transcatheter mitral repair has the potential to supplant surgical repair or replacement as the gold-standard treatment for persistent mitral regurgitation. Currently, these interventions are only performed on high-risk surgical candidates, but the indications may eventually be expanded to include low-to-intermediate risk patients as well, in a manner like transcatheter aortic valve replacement. In patients with ischemic cardiomyopathy who still had considerable viable myocardium, combining current guideline-directed pharmacological treatment with interventional complete revascularization decreased hospitalizations for heart failure. We performed a CHIP intervention on the left circumflex artery, which was chronically totally occluded, to address the severe ischemic mitral regurgitation that had been present for a long time.

TCTAP C-074 High-Risk Coronary Intervention to the ‘Last Standing’ Left Circumflex Artery

TCTAP C-074 High-Risk Coronary Intervention to the ‘Last Standing’ Left Circumflex Artery

Short- and long-term outcomes of percutaneous coronary interventions of high-risk vs. low-risk lesions performed at a hospital without an on-site cardiac surgery unit.

Aim Widespread utilization of technology has led to the construction of a growing number of facilities with coronary angiography units and percutaneous coronary intervention (PCI) capability. Some of these centers do not have cardiovascular surgery (CVS) on site. Studies regarding the efficacy and safety of PCIs performed at these hospitals have been conducted. However, to date, high-risk procedures in this context have not been evaluated. The present study compares the outcomes of PCI procedures performed on high- and low-risk lesions groups in a center without CVS back-up.Material and methods A total of 999 patients treated with PCI with diagnoses other than ST elevation myocardial infarction were included in this study. Patients with SYNTAX scores 22 or higher, bifurcation lesions, chronic total occlusions, left main coronary artery lesions and saphenous graft lesions were classified as a high-risk group. In contrast, patients with SYNTAX scores lower than 22 were included in the low-risk group. Coronary lesions were classified as Type-A, B, and C. The 30‑day major adverse cardiac events (MACE) and 1‑year target vessel revascularization (TVR) rates were compared.Results There was no significant difference between the groups in terms of the rates of MACE (2 (0.9 %) vs 5 (0.6 %); p=0.64) and TVR (9 (4.2 %) vs 25 (3.2 %); p=0.52). Analysis regarding the lesion type also revealed no significant difference between the MACE and TVR rates (p=0.56 and p=0.43, respectively).Conclusions The findings in this study demonstrated that, similar to low-risk procedures, complex and high-risk coronary interventions can safely and effectively be conducted in hospitals without a CVS unit.

A new iteration for the single-access large-bore technique during Impella supported complex and high-risk coronary intervention: a case report

BackgroundComplex and high-risk coronary intervention (CHIP-PCI) and PCI in cardiogenic shock complicating acute coronary syndrome (ACS) are increasingly performed under mechanical circulatory support—so-called protected PCI. Among the available options, Impella Cardiac Power (CP) heart pump (Abiomed) is percutaneously inserted over the femoral artery and typically requires a second arterial access to perform PCI, which further enhances the risk of vascular and bleeding complications. The single-access technique allows Impella CP placement and PCI performance through the same vascular access. When a 7 Fr system is desirable, only a long and entirely hydrophilic coated sheath has been previously used, which is not available in Europe.Case summaryA 85-year-old patient admitted with non ST-elevation - acute coronary syndrome (NSTE-ACS), severely reduced left ventricular function and three-vessel coronary artery disease underwent single-access CHIP-PCI under Impella CP support. After a failed attempt to insert a standard 7 Fr long femoral sheath alongside the Impella catheter, we successfully introduced a 7.5 Fr sheathless guiding catheter and delivered the planned percutaneous treatment with the benefits conferred by a 7 Fr—rather than 6—lumen catheter, without the need for an additional arterial access.DiscussionThis is, to the best of our knowledge, the first case of CHIP-PCI performed under Impella support utilizing the single-access technique with a 7.5 Fr sheathless guiding catheter. Beyond advantages of the single-access technique in sparing time and avoiding vascular complications associated with gaining a second arterial access, the lower outer diameter of the sheathless catheter compared with standard 7 Fr sheaths may allow improved limb perfusion and lower chance of interference with the Impella CP catheter.

Gender based outcome of IABP implantation in patients with acute coronary syndrome and cardiogenic shock: a national inpatient sample database analysis

Abstract Background Intra-Aortic Balloon counter-pulsation is frequently used as a circulatory support device in patients requiring hemodynamic support - in cardiogenic shock and in patients at risk of hemodynamic decompensation during a high-risk coronary intervention. Impact of IABP in this patient population has been variable. Certain studies have shown a beneficial effect of IABP on selected populations having acute coronary syndrome with cardiogenic shock (1–3). Our objective was to compare the outcomes based on gender in the ACS population with cardiogenic shock and IABP placement. Methods We analyzed the National Inpatient Sample database from Oct-2015 to Dec-2017 released under Healthcare Cost utilization Project in the USA using Stata 16.0. The population was identified using respective ICD-10 codes. We excluded the population with sudden cardiac arrest, pulmonary embolism, and patients with anatomical post-MI complications. Multivariate logistic regression analysis was done to determine the difference in outcomes based on gender using clinically relevant variables. Later, propensity-matched cohort analysis was performed based on the regression variables. Results Of 36, 990 patients who met our inclusion criteria 25,670 (69%) were male and 11,320 (31%) were female. The average age for male and female populations was 66±11 and 69±12 years. Femnales were more likely to have higher Charlson co-morbidity index three or above. We found higher mortality in the female population [3,146 (27.79%)] compared to male [5,884 (22.92%)] in univariate analyses. Propensity-matched multivariate regression analysis showed no difference [OR: 1.06 (0.91–1.22) with P-value: 0.482] in mortality after adjusting for clinically relevant variables. Subgroup analysis in STEMI and NSTEMI populations did not show a difference. The average hospital stay was similar in both cohorts, with the male having a higher cost per stay. We found no difference in most of the complications included in our study except for higher coronary artery dissection [OR: 2.98 (1.73–5.13), P-value: <0.001] and lower rates of AKI [OR: 0.72 (0.63–0.83), P-value: <0.001], AKI requiring hemodialysis [OR: 0.74 (0.56–0.97), P-value:0.031] and ventricular tachycardia [OR: 0.73 (0.64–0.84), P-value: <0.001] in the female population. Conclusion The inpatient population of ACS with Cardiogenic shock and IABP insertion showed no significant difference in mortality between males and females which was valid for subgroup analysis of NSTEMI and STEMI groups. Complications such as coronary artery dissection were higher, whereas AKI, AKI requiring hemodialysis, and ventricular tachycardias, were lower in females than males. Funding Acknowledgement Type of funding sources: None.

Tunnelling a calcified total occlusion.

Among the complex and high-risk coronary intervention cases, a calcified total occlusion of coronary artery poses a great challenge. We came across a 48 years old male who had calcified total occlusion of the right coronary artery. The chronic total occlusion was crossed using Nic-Nano balloon and the calcific plaque was modified using intravascular lithotripsy as an alternative technique to rotational atherectomy which we felt as an evolving alternative approach to treat the calcified total occlusion.

Aortix™: a novel intra-aortic entrainment pump.

Use of short-term mechanical circulatory support pumps for cardiogenic shock, decompensated heart failureand high-risk coronary intervention is growing. The Aortix™ device (Procyrion, TX, USA) is the first axial-flow pump positioned in the aorta and is designed to provide short-term hemodynamic support. This review discusses the field of continuous flow aortic pumps and focuses specifically on emerging preclinical and clinical data supporting the development of these technologies.

TCT CONNECT-152 Comparing the Rate of Side Branch Occlusion Between Jailed Balloon Technique and Jailed Wire Technique During High-Risk Coronary Bifurcation Intervention: Subgroup Analysis of the CIT-RESOLVE Trial

TCT CONNECT-152 Comparing the Rate of Side Branch Occlusion Between Jailed Balloon Technique and Jailed Wire Technique During High-Risk Coronary Bifurcation Intervention: Subgroup Analysis of the CIT-RESOLVE Trial

Training in high-risk coronary procedures and interventions: Recommendations for core competencies.

Training in high-risk coronary procedures and interventions: Recommendations for core competencies.

The Characteristics and Clinical Outcomes of Rotational Atherectomy under Intra-Aortic Balloon Counterpulsation Assistance for Complex and Very High-Risk Coronary Interventions in Contemporary Practice: An Eight-Year Experience from a Tertiary Center.

The use of Complex and High-risk Coronary Interventions (CHIPs) has increased in recent years. Both rotational atherectomy (RA) and hemodynamic support are important parts of CHIPs. This study aimed to retrospectively investigate the procedure results and clinical outcomes of intra-aortic balloon pump (IABP)-assisted RA in the contemporary drug-eluting stent era. All consecutive patients who received RA under in-procedure IABP assistance from April 2010 to March 2018 were analyzed retrospectively. A total of 63 patients (77.7 ± 10.1 years, 69.8% male) were recruited, of whom 51 underwent RA with primary IABP assistance and 12 underwent bailout IABP. RA could be completed in 61 (96.8%) of the patients. Overall, vessel perforation, profound in-procedure shock, and ventricular arrhythmia occurred in 1.6%, 4.8% and 3.2% of the patients, respectively. The in-hospital, 30-day and 90-day major adverse cardiac event (MACE) rates were 22.2%, 27.4% and 36.1%, respectively, mostly driven by mortality. The MACE rates were significantly higher in the bail-out group in the hospital (50.0% vs. 15.7%, p = 0.018) at 30 days (58.3% vs. 20.0%, p = 0.013) and 90 days (66.7% vs. 28.6%, p = 0.020). Bail-out IABP was associated with increased MACEs, implying that the use of IABP should be implemented at the beginning of RA if a complex procedure is anticipated.

LEVERAGING THE LAW OF LAPLACE: SUCCESSFUL TRANSCAVAL ACCESS THROUGH AN ABDOMINAL AORTIC ANEURYSM FOR IMPELLA ASSISTED DISTAL LEFT MAIN INTERVENTION FOLLOWED BY SELF EXPANDING TAVR VALVE

CAD is often accompanied by PAD which can limit options for percutaneous revascularization. This case highlights balancing the biomechanics of abdominal aortic aneurysms to gain transcaval arterial access for a high risk coronary intervention and TAVR. An 81 yo F with a known AAA and bilateral

CRT-200.19 Reported Complications Received in 2019 for Percutaneous Left Ventricular Assist Devices in the MAUDE Database

The use of percutaneous left ventricular assist devices for cardiogenic shock and high-risk coronary interventions has been increasing steadily. However, there are significant device-associated complications leading to significant morbidity and mortality. The Manufacturer and User Facility Device

Safety and efficacy of a novel algorithm to guide decision-making in high-risk interventional coronary procedures

BackgroundPatients with severe coronary artery disease (CAD), comorbidities, or impaired hemodynamics are at risk during percutaneous coronary interventions. The aim of the study was to investigate the safety and efficacy of a novel risk-stratification algorithm for high-risk coronary procedures. Methods and resultsWe prospectively screened 1189 patients with CAD requiring revascularization (period 07/2017–06/2018). The algorithm was designed to select high-risk procedures. Patients with elevated risk (n = 150) were classified into 3 risk groups (high-risk intervention [HRI] I–III) and procedural management was adjusted according to HRI group. Overall, 55 patients were categorized as HRI I, 52 as HRI II, and 43 as HRI III. With increasing HRI-level, SYNTAX score increased (HRI I:15 ± 5% vs. HRI II:24 ± 8% vs. HRI III:34 ± 7%; p < 0.001), and ejection-fraction decreased (HRI I:48 ± 10% vs. HRI II:49 ± 10% vs. HRI III:40 ± 11%; p < 0.001). The primary endpoint (hemodynamic compromise requiring mechanical circulatory support [MCS] [HRI I/II], unsuccessful weaning from MCS in the catheterization laboratory[HRI III], or periprocedural death[HRI I–III]) occurred in no case. The secondary endpoint of hemodynamic deterioration occurred in 26% (n = 39) but did not result in hemodynamic instability due to the risk-adjusted procedural management. The composite endpoint of in-hospital major adverse cardiac and cerebrovascular events (death, new myocardial infarction, cerebrovascular accident) occurred in 4 patients (3%). ConclusionsThe novel algorithm is a safe team-based stratification method for the identification and management of patients undergoing high-risk coronary interventions.

RADIAL ARTERY OCCLUSION FOLLOWING TRANSRADIAL CORONARY INTERVENTION

Objective: To determine the frequency of radial artery occlusion followingtransradial coronary intervention in acute myocardial infarction patients. Methodology: This cross-sectional study was conducted at cardiologydepartment Liaqat National Hospital Karachi from 22nd October 2016 to 21stApril 2017. Patients with myocardial infarction going for coronary interventionperformed through radial artery were recruited in this study. Radial artery waspalpated and coronary artery intervention was performed through radial arteryafter procedure patient was shifted to recovery, palpate radial artery after 6hrsand then Doppler ultrasonography was performed which shows no flow,impaired flow or normal laminar flow. Results: A total of 180 patients with myocardial infarction going for coronaryintervention performed through radial artery were recruited in this study. About79% of the patients were above 4 years of age. There were 55.56% male.Diabetes and hypertension were the commonest factor followed by smoking.Frequency of radial artery occlusion following transradial coronary interventionin acute myocardial infarction was observed in 18.89% cases. With respect toage stratification, rate of radial artery occlusion was observed in the range of14.3% to 23.7% in different age groups (p=0.734). Rate of radial arteryocclusion was approximate similar in male and female (p=0.96) while rate ofocclusion was significantly higher in obese (BMI >30 kg/m2) as compared to theoverweight and normal cases (p=0.011). Conclusion: The use of transradial PCI is not only beneficial to reduce bleedingbut also for ischemic complications and mortality in high-risk patientsundergoing coronary interventions. Key Words: Transradial coronary angiography, Radial artery occlusion, Acutemyocardial infarction.

A systematic literature review and meta-analysis of impella devices used in cardiogenic shock and high risk percutaneous coronary interventions

Background: To perform a meta-analysis on pooled survival and complications rates of Impella® heart pumps (Abiomed Inc., Danvers, USA) use in cardiogenic shock and high-risk coronary percutaneous coronary intervention (PCI). Methods and Findings: Articles were searched in Medline, Medline In-Process, EMBASE and the CENTRAL bibliographic databases on the 30th April, 2017. Prospective and retrospective studies with ≥10 patients supported with Impella. Survival and complication rates were pooled. The literature review identified 33 articles. Data on patient characteristics, indication of support, type of Impella device and outcomes were extracted. A random effect was used to pool the various outcomes. Low heterogeneity (I2 ≤0.25) results are presented. A total of 2,827 patients (40.5% cardiogenic shock, 59.5% high-risk PCI) were included (mean age 64.9±11.4, male 74.6%). In the cardiogenic shock indication, survival rate to 90 and 180 days was 62.6% and 58.3%, respectively; the rates of hemolysis and device malfunction were 8.8% and 2.5%, respectively. In the high-risk PCI indication, the 30 day major adverse cardiac and cerebrovascular event (MACCE) rate was 15.3% with a 30 day survival, stroke, myocardial infarction and repeat revascularization rates of 92.2%, 0.3%, 13.5% and 1.6%, respectively. Hemolysis and device malfunction affected respectively 0.7% and 1.4% of the high-risk PCI patients. Conclusions: This is the largest meta-analysis summarizing the literature outcome data of Impella heart pumps. The present study demonstrates very encouraging survival in cardiogenic shock patients and very good 30 day outcomes in patients undergoing prophylactic support for high-risk PCI.