High-risk Percutaneous Coronary Intervention Research Articles

Role of mechanical circulatory support in VT ablation procedures: data from the German PROTECT VT registry

Abstract Introduction Ventricular tachycardia (VT) ablation in patients with progressed heart failure (HF) is known to be complex and associated with a high periprocedural risk and mortality, in part due due to hemodynamic instability during ongoingVTs. Use of mechanical circulatory support (MCS) systems has been already implemented in complex high-risk percutaneous coronary intervention (CHIP-PCI) workflows. Use and benefit of MCS in VT ablation is still under debate. MCS protected VT ablation (proVT-A) might be associated with improved clinical outcomebut potentially comes along with an increased risk of periprocedural complications. Based on data of four German high-volume centers we aimed to analyze retrospective data on patient characteristics and impact of proVT-A with respect to safety and mid-term efficacy. Methods All patients undergoing proVT-A as a primary approach from four German EP centers were included in the analysis. Use of MCS in bailout scenariosin VT ablation were not included. Patient characteristics, procedural parameters and clinical outcome were evaluated. The primary endpoint was a combined endpoint of VT/VF recurrence and all-cause death. Results 41 patients who underwent proVT-A were included. Mean age was 64±11a, 92% of patients were male (38/41), 65% (27/41) suffered from ischemic cardiomyopathy, mean left ventricular ejection fraction was 33±13%,76% (31/41) of patients presented with a documented hemodynamically not tolerated VT, mean PAAIN-ESD score was 13±7, and 46% (19/41) had a history of a previous VT ablation w/o MCS. During proVT-A procedure at least one VT was inducible and mappable in 35 patients (85%). Acute procedural success was 85%, with only n=6 patients remaining inducible for VT. Mean procedure duration was 245±46min. With respect to periprocedural safety (30days)a total of n=12 relevant procedural complications were reported in 8 patients. This included n=5 vascular access complications, of which n=3 requiring transfusion or surgery. One case of periprocedural death was reported 6h post proVT-A due to PEA. Three patients developed pericardial effusion, one requiring drainage. Freedom from VT/VF was 78% (n=9 VT/VF recurrences) after a mean follow-up (FU) of 15±14 months (figure 1A). Death of any cause occurred in n=9 patients (figure 1B). In summary, after a mean FU of 15±14 months n=16 patients (39%) met the combined endpoint of VT/VF recurrence and all-cause death (figure 1C). Conclusion Patients enrolled in the German PROTECT VT Registry had significant cardiovascular comorbidities and therefore represent a high-risk population for VT ablation. Use of MCS was feasible, comparably safe, associated with high procedural and promising long-term success rate. These results highlight the need for larger registries and future prospective trials evaluating the potential benefit of proVT-A in selected patients. Further, it should be aimed for optimization of periprocedural vascular access site management.

Effect of Extracorporeal Membrane Oxygenation Support on Complex High-Risk Elective Percutaneous Coronary Intervention: A Clinical Research Review of Progress and Outcomes

Background: The landscape of percutaneous coronary intervention (PCI) has expanded to encompass complex high-risk elective cases, necessitating advanced support strategies to mitigate procedural challenges and ensure patient safety. In this review manuscript, the effect of extracorporeal membrane oxygenation (ECMO) support on complex high-risk elective PCI was critically evaluated through an analysis of relevant clinical studies. The objective is to elucidate the role of ECMO in optimizing procedural success, mitigating complications, and improving long-term patient outcomes in this high-stake domain of interventional cardiology. Methods: A comprehensive search strategy identified seven publications encompassing single-center prospective, retrospective, and case report designs, collectively involving 91 patients undergoing high-risk elective PCI with ECMO support. Results: The results from these studies demonstrated the potential of ECMO support to facilitate successful high-risk elective PCI with favorable procedural outcomes, highlighting the importance of careful patient selection and proactive management of potential complications to further optimize the use of ECMO in this clinical setting. The refinement of patient selection criteria, optimization of procedural techniques, and assessment of long-term clinical outcomes following ECMO-assisted high-risk PCI procedures represent crucial avenues for future research. Conclusions: Overall, the reviewed evidence supports the notion that ECMO represents a valuable tool for providing hemodynamic support during high-risk PCI procedures, particularly in patients deemed at very high risk for surgical revascularization.

SCAI SHOCK stage classification: valid for all indications and devices in patients with short-term mechanical circulatory support?

Abstract Funding Acknowledgements None. Background The Society for Cardiovascular Angiography and Intervention (SCAI) SHOCK stage has demonstrated prognostic value in patients with cardiogenic shock (CS), including patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. It has also been validated in different scenarios as acute coronary syndrome -ACS- or out-of-hospital cardiac arrest. Purpose Our objective was to study the prognostic value of SCAI SHOCK stage in different indications and etiologies requiring different types of short-term mechanical circulatory support (MCS). Methods Retrospective analysis of consecutive patients supported with VA-ECMO or Impella CP® in a referral center. We studied the SCAI SHOCK stage at MCS implantation according different devices, indication and etiology, and its relationship with in-hospital and follow-up survival. Results 263 patients were included between 2014-March 2023 (Table). The SCAI SHOCK stage was less advanced in complex high risk percutaneous coronary intervention (CHIP-PCI) indication and more advanced in postcardiotomy shock, myocarditis, pulmonary embolism (PE), refractory cardiac arrest or electric storm (Figure A). In-hospital survival was 41.1% and it was significantly lower as SCAI SHOCK stage increased (A 83.9%, B 100%, C 66.7%, D 39.2%, E 24.5%; p=0.000), as well as in follow-up for a median time of 24.5 [47] months (figure B). This association was maintained with both types of devices separately: VA-ECMO (A 80%, B 100%, C 33.3%, D 38.9%, E 24.5%, p=0.001) and Impella (A 84%, B 100%, C 75%, D 42.9%, E 25%, p=0.005). Regarding the indication and etiology for MCS, SCAI SHOCK classification was significantly related with survival in CS indication, as well as in ACS and heart failure (HF) etiology (Figure B). However, no relationship between SCAI and survival was observed in indications as CHIP-PCI (A 83.9%, B 100%, C 50%; p=0.386), electrical storm (C 0%, D 100%, E 70%; p=0.075) and postcardiotomy shock (D 35.6%, E 20%; p=0.470), neither in etiologies as PE (D 0%, E 28.6%; p=1), infective endocarditis (D 28.6%, E 0%; p=1), myocarditis (D 100%, E 0%; p=0.250),and other causes of cardiac arrest (D 0%, E 25%; p=1), nor in patients admitted for elective cardiac surgery. Conclusions SCAI SHOCK stage classification showed prognostic value in patients with short-term MCS indicated by diverse etiologies, including both VA-ECMO and Impella CP devices. The prognostic value was maintained for the indication of CS, and in ACS and HF etiologies, but not in electrical storm, CHIP-PCI, PE, myocarditis or postcardiotomy shock. Studies are needed to validate this classification in other settings.TableFigure

Angiographic Characteristics and Clinical Outcomes in Patients With Chronic Kidney Disease Undergoing Impella-Supported High-Risk Percutaneous Coronary Intervention: Insights From the cVAD PROTECT III Study.

Prior studies have found that patients with chronic kidney disease (CKD) have worse outcomes following percutaneous coronary intervention (PCI). There are no data about patients with advanced CKD undergoing Impella-supported high-risk PCI. We, therefore, aimed to evaluate angiographic characteristics and clinical outcomes in patients with CKD who received Impella-supported high-risk PCI as part of the catheter-based ventricular assist device PROTECT III study (A Prospective, Multi-Center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump [IABP] in Patients Undergoing Non Emergent High Risk PCI). Patients enrolled in the PROTECT III study were analyzed according to their baseline estimated glomerular filtration rate (eGFR). The primary outcome was 90-day major adverse cardiovascular and cerebrovascular events (the composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization). Of 1237 enrolled patients, 1052 patients with complete eGFR baseline assessment were evaluated: 586 with eGFR ≥60 mL/min per 1.73 m2, 190 with eGFR ≥45 to <60, 105 with eGFR ≥30 to <45, and 171 with eGFR <30 or on dialysis. Patients with lower eGFR (all groups with eGFR <60) were more frequently females and had a higher prevalence of hypertension, diabetes, anemia, and peripheral artery disease. The baseline Synergy Between PCI With Taxus and Cardiac Surgery score was similar between groups (28.2±12.6 for all groups). Patients with lower eGFR were more likely to have severe coronary calcifications and higher usage of atherectomy. There were no differences in individual PCI-related coronary complications between groups, but the rates of overall PCI complications were less frequent among patients with lower eGFR. Major adverse cardiovascular and cerebrovascular events at 90 days and 1-year mortality were significantly higher among patients with eGFR <30 mL/min per 1.73 m2 or on dialysis. Patients with advanced CKD undergoing Impella-assisted high-risk PCI tend to have higher baseline comorbidities, severe coronary calcification, and higher atherectomy usage, yet CKD was not associated with a higher rate of immediate PCI-related complications. However, 90-day major adverse cardiovascular and cerebrovascular events and 1-year mortality were significantly higher among patients with eGFR<30 mL/min per 1.73 m2 or on dialysis. Future studies of strategies to improve intermediate and long-term outcomes of these high-risk patients are warranted. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04136392.

C-51 | Evaluation of outcomes of high risk percutaneous coronary intervention in patients with and without prior CABG

C-51 | Evaluation of outcomes of high risk percutaneous coronary intervention in patients with and without prior CABG

D-51 | Outcomes Among Patients with Coronary Bifurcation Lesions Undergoing Impella-Supported High-Risk Percutaneous Coronary Intervention

D-51 | Outcomes Among Patients with Coronary Bifurcation Lesions Undergoing Impella-Supported High-Risk Percutaneous Coronary Intervention

OR2-3 | The Impact of Age in Patients Undergoing Impella-Assisted High-Risk Percutaneous Coronary Intervention: It Gets Complicated

OR2-3 | The Impact of Age in Patients Undergoing Impella-Assisted High-Risk Percutaneous Coronary Intervention: It Gets Complicated

Characteristics of Patients Undergoing High-Risk Percutaneous Coronary Intervention in Contemporary United States Practice

Characteristics of Patients Undergoing High-Risk Percutaneous Coronary Intervention in Contemporary United States Practice

Percutaneous intravascular micro-axial blood pump: current state and perspective from engineering view.

The utilization of a minimally invasively placed catheter-mounted intravascular micro-axial flow blood pump (IMFBP) is increasing in the population with advanced heart failure. The current development of IMFBPs dates back around the 1990s, namely the Hemopump with a wire-drive system and the Valvopump with a direct-drive system. The wire-drive IMFBPs can use a brushless motor in an external console unit to transmit rotational force through the drive wire rotating the impeller inside the body. The direct-drive IMFBPs require an ultra-miniature and high-power brushless motor. Additionally, the direct-drive system necessitates a mechanism to protect against blood immersion into the motor. Therefore, the direct-drive IMFBPs can be categorized into two types of devices: those with seal mechanisms or those with sealless mechanisms using magnetically coupling. The IMFBPs can be classified into two groups depending on their purpose. One group is for cardiogenic shock following a heart attack or for use in high-risk percutaneous coronary intervention (PCI), and the other group serves the purpose of acute decompensated heart failure. Both direct-drive IMFBPs and wire-drive IMFBPs have their own advantages and disadvantages, and efforts are being made to develop and improve, and clinically implement them, leveraging their own strengths. In addition, there is a possibility that innovative new devices may be invented. For researchers in the field of artificial heart development, IMFBPs offer a new area of research and development, providing a novel treatment option for severe heart failure.

Association of Preprocedural SYNTAX Score With Outcomes in Impella-Assisted High-Risk Percutaneous Coronary Intervention

BackgroundPatients with complex coronary artery disease, as defined by high SYNTAX scores, undergoing percutaneous coronary intervention (PCI) have poorer outcomes when compared with patients with lower SYNTAX I scores. This study aimed to assess if mechanical circulatory support using Impella mitigates the effect of the SYNTAX I score on outcomes after high-risk percutaneous coronary intervention (HRPCI). MethodsUsing data from the PROTECT III study, patients undergoing Impella-assisted HRPCI between March 2017 and March 2020 were divided into 3 cohorts based on SYNTAX I score—low (≤22), intermediate (23-32), and high (≥33). Procedural and clinical outcomes out to 90 days were compared between groups. Multivariable regression analysis was used to assess the impact of SYNTAX I score on major adverse cardiovascular and cerebrovascular events (MACCE) at 90 days. ResultsA total of 850 subjects with core laboratory–adjudicated SYNTAX I scores were identified (low: n = 310; intermediate: n = 256; high: n = 284). Patients with high SYNTAX I scores were older than those with low or intermediate SYNTAX I scores (72.7 vs 69.7 vs 70.1 years, respectively; P < .01). After adjustment for covariates, high SYNTAX I score remained a significant predictor of 90-day MACCE (hazard ratio [HR], 2.14; 95% CI, 1.42-3.69; P < .01 vs low), whereas intermediate SYNTAX I score was not (HR, 0.92; 95% CI, 0.47-1.77; P = .80 vs low). These findings persisted after adjustment for post-PCI SYNTAX I score. ConclusionsA high SYNTAX I score was associated with higher rates of 90-day MACCE in patients who underwent Impella-assisted HRPCI. Further research is needed to understand the patient and procedural factors driving this finding.

In-Stent Restenosis Overview: From Intravascular Imaging to Optimal Percutaneous Coronary Intervention Management.

Despite ongoing progress in stent technology and deployment techniques, in-stent restenosis (ISR) still remains a major issue following percutaneous coronary intervention (PCI) and accounts for 10.6% of all interventions in the United States. With the continuous rise in ISR risk factors such as obesity and diabetes, along with an increase in the treatment of complex lesions with high-risk percutaneous coronary intervention (CHIP), a substantial growth in ISR burden is expected. This review aims to provide insight into the mechanisms, classification, and management of ISR, with a focus on exploring innovative approaches to tackle this complication comprehensively, along with a special section addressing the approach to complex calcified lesions.

Mechanical Circulatory Support for High-Risk Percutaneous Coronary Intervention.

This review will focus on the indications of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) and then analyze in detail all MCS devices available to the operator, evaluating their mechanisms of action, pros and cons, contraindications, and clinical data supporting their use. Over the last decade, the interventional cardiology arena has witnessed an increase in the complexity profile of the patients and lesions treated in the catheterization laboratory. Patients with significant comorbidity burden, left ventricular dysfunction, impaired hemodynamics, and/or complex coronary anatomy often cannot tolerate extensive percutaneous revascularization. Therefore, a variety of MCS devices have been developed and adopted for high-risk PCI. Despite the variety of MCS available to date, a detailed characterization of the patient requiring MCS is still lacking. A precise selection of patients who can benefit from MCS support during high-risk PCI and the choice of the most appropriate MCS device in each case are imperative to provide extensive revascularization and improve patient outcomes. Several new devices are being tested in early feasibility studies and randomized clinical trials and the experience gained in this context will allow us to provide precise answers to these questions in the coming years.

Invasiveness of previous treatment for peripheral arterial disease and risk of adverse cardiac events after coronary stenting

Patients with peripheral arterial disease (PADs), undergoing percutaneous coronary intervention (PCI), have higher adverse event risks. The effect of invasiveness of PADs treatment on PCI outcome is unknown. This study assessed the impact of the invasiveness of previous PADs treatment (invasive or non-invasive) on event risks after PCI with contemporary drug-eluting stents. This post-hoc analysis pooled 3-year patient-level data of PCI all-comer patients living in the eastern Netherlands, previously treated for PADs. PADs included symptomatic atherosclerotic lesion in the lower or upper extremities; carotid or vertebral arteries; mesenteric arteries or aorta. Invasive PADs treatment comprised endarterectomy, bypass surgery, percutaneous transluminal angioplasty, stenting or amputation; non-invasive treatment consisted of medication and participation in exercise programs. Primary endpoint was (coronary) target vessel failure: composite of cardiac mortality, target vessel-related myocardial infarction, or clinically indicated target vessel revascularization. Of 461 PCI patients with PADs, information on PADs treatment was available in 357 (77.4%) patients; 249 (69.7%) were treated invasively and 108 (30.3%) non-invasively. Baseline and PCI procedural characteristics showed no between-group difference. Invasiveness of PADs treatment was not associated with adverse event risks, including target vessel failure (20.5% vs. 16.0%; HR: 1.30, 95%-CI 0.75–2.26, p = 0.35), major adverse cardiac events (23.3% vs. 20.4%; HR: 1.16, 95%-CI 0.71–1.90, p = 0.55), and all-cause mortality (12.1% vs. 8.3%; HR: 1.48, 95%-CI 0.70–3.13, p = 0.30). In PADs patients participating in PCI trials, we found no significant relation between the invasiveness of previous PADs treatment and 3-year outcome after PCI. Consequently, high-risk PCI patients can be identified by consulting medical records, searching for PADs, irrespective of the invasiveness of PADs treatment.Graphical abstractComparison of patients with non-invasive and invasive PADs treatment. PADs peripheral arterial disease, PCI percutaneous coronary intervention.

The use of mechanical circulatory support in elective high-risk percutaneous coronary interventions: a literature-based review.

Contemporary medical practices allow complete percutaneous coronary intervention (PCI) in a considerable number of patients who previously would have been considered too 'high-risk' for such procedures. The use of mechanical circulatory support (MCS) devices during these high-risk PCIs (HR-PCIs) is thought to reduce the potential risk for major adverse events during and after revascularization. The intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO), and the Impella are the most common MCS devices in use. This review aims to summarize the clinical evidence for each of these devices and the potential mechanisms for the improvement in patient outcomes in HR-PCI. The IABP use has rapidly declined in recent years due to no evidence of benefit in HR-PCI and cardiogenic shock. The V-A ECMO results in low rates of major adverse cardiac and cerebrovascular events (MACCEs) but higher rates of acute kidney injury and increased need for transfusions. In initial studies, Impella resulted in a reduced need for repeat interventions and reduced rates of hypotension, but no benefit in mortality. However, MACCE rates with Impella have gradually declined over the last 10 years, reflecting increased operator experience and technical improvements. Thus, a large, randomized trial is needed to assess the efficacy of Impella in HR-PCI with contemporary standards of care. There is currently no individual parameter that can identify patients who would benefit from MCS use in elective HR-PCI. To address this gap, we propose an algorithm that combines anatomical complexity, comorbidities, and clinical presentation to accurately identify candidates for MCS-assisted HR-PCI.

Predictors of left ventricular ejection fraction in high-risk percutaneous coronary interventions.

Revascularization completeness after percutaneous coronary intervention (PCI) is associated with improved long-term outcomes. Mechanical circulatory support [intra-aortic balloon pump (IABP) or Impella] is used during high-risk PCI (HR-PCI) to enhance peri-procedural safety and achieve more complete revascularization. The relationship between revascularization completeness [post-PCI residual SYNTAX Score (rSS)] and left ventricular ejection fraction (LVEF) in HR-PCI has not been established. We investigated LVEF predictors at 90 days post-PCI with Impella or IABP support. Individual patient data (IPD) were analyzed from PROTECT II (NCT00562016) in the base case. IPD from PROTECT II and RESTORE-EF (NCT04648306) were naïvely pooled in the sensitivity analysis. Using complete cases only, linear regression was used to explore the predictors of LVEF at 90 days post-PCI. Models were refined using stepwise selection based on Akaike Information Criterion and included: treatment group (Impella, IABP), baseline characteristics [age, gender, race, New York Heart Association Functional Classification, LVEF, SYNTAX Score (SS)], and rSS. Impella treatment and higher baseline LVEF were significant predictors of LVEF improvement at 90 days post-PCI (p ≤ 0.05), and a lower rSS contributed to the model (p = 0.082). In the sensitivity analysis, Impella treatment, higher baseline LVEF, and lower rSS were significant predictors of LVEF improvement at 90 days (p ≤ 0.05), and SS pre-PCI contributed to the model (p = 0.070). Higher baseline LVEF, higher SS pre-PCI, lower rSS (i.e. completeness of revascularization), and Impella treatment were predictors of post-PCI LVEF improvement. The findings suggest potential mechanisms of Impella include improving the extent and quality of revascularization, and intraprocedural ventricular unloading.

Structured Weaning From the Impella Left Ventricular Micro-Axial Pump in Acute Myocardial Infarction With Cardiogenic Shock and Protected Percutaneous Coronary Intervention: Experience From a Non-Cardiac Surgical Centre

The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction-cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined. We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters. Ten patients (eight male, two female; aged 43-70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C-E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4-48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%. A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol.

СЕРИЯ КЛИНИЧЕСКИХ СЛУЧАЕВ ПРИМЕНЕНИЯ ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИИ ПРИ ВЫПОЛНЕНИИ ЧКВ ВЫСОКОГО РИСКА

Introduction. Percutaneous coronary interventions (PCI) have become increasingly intricate, particularly considering patient comorbidities. The simultaneous or staged coronary artery stenting in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease during the index hospitalization has garnered considerable interest. The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in PCI has notably increased, serving both as an emergency intervention in acute myocardial infarction (AMI) and in planned PCI to maintain hemodynamics and organ perfusion. The term "high-risk PCI" has been introduced to denote interventions performed using short-term mechanical circulatory support, necessitating a multidisciplinary approach for patient management. Aim. This study aims to investigate the management approaches for high-risk PCI patients using mechanical circulatory support methods. Materials and Methods. A comprehensive literature review on the management of high-risk PCI patients was conducted. Patients with STEMI who underwent LCA trunk stenting at the bifurcation site using ECMO were selected based on the Barnaul ACCD. Results. Data on ECMO use in high-risk PCI are primarily limited to single-center observational studies or individual clinical cases. In the presented cases, ECMO facilitated successful implementation of complex PCI in patients with STEMI and critical stenoses of large coronary arteries. Indications for routine use of mechanical devices during PCI procedures should be individualized, considering potential benefits and complications. In the cases presented, ECMO use during XRD enabled complete revascularization despite acute heart failure and cardiogenic shock, leading to rapid patient stabilization and discharge in satisfactory condition. Conclusions. Managing high-risk PCI patients necessitates a multidisciplinary approach, requiring collaboration among endovascular surgeons, clinical cardiologists, and cardiac surgeons. Critical aspects in the intensive care unit for these patients are not yet fully understood, emphasizing the need to optimize patient condition pre-procedure, manage concurrent diseases, and ensure adequate postoperative care. The synergy between intensive care specialists and cardiologists can significantly impact treatment outcomes in this clinical context.

Clinical characteristics and outcomes of patients requiring prolonged mechanical circulatory support after high-risk percutaneous coronary intervention.

There are limited data on the clinical characteristics and outcomes of patients who require prolonged mechanical circulatory support (MCS) after Impella-supported high-risk percutaneous coronary intervention (HR-PCI). The aim of this study is to describe the contemporary clinical characteristics, outcomes, and predictors associated with prolonged MCS support after assisted HR-PCI. Patients enrolled in the prospective, multicentre, clinical endpoint-adjudicated PROTECT III study who had undergone HR-PCI using Impella were evaluated. Patient and procedural characteristics and outcomes for those who received prolonged MCS beyond the duration of their index procedure were compared to those in whom MCS was successfully weaned and explanted at the conclusion of the index PCI. Among 1,155 patients who underwent HR-PCI with Impella between 2017 and 2020 and had sufficient data to confirm theduration of Impella support, 16.5% received prolonged MCS (mean duration 25.2±31.1 hours compared with 1.8±5.8 hours for those who only received intraprocedural MCS). Patients receiving prolonged support presented with more urgent indications (e.g., acute coronary syndromes [ACS], lower ejection fraction [EF], elevated baseline heart rate and lower systolic blood pressure). Use of the Impella CP, intraprocedural complications, periprocedural complications and in-hospital mortality were all more common amongst the prolonged MCS group. Prolonged MCS was associated with increased rates of major adverse cardiovascular and cerebrovascular events, cardiovascular death, and all-cause mortality at 90-day follow-up. Patients receiving prolonged MCS after Impella-supported HR-PCI presented with more ACS, reduced EF and less favourable haemodynamics. Additionally, they were more likely to experience intraprocedural and periprocedural complications as well as increased in-hospital and post-discharge mortality.

Combined Rotational excimer lASER coronary atherectomy (RASER) in non-crossable, non-dilatable coronary artery disease: observations from a single center.

Balloon non-crossable stenoses represent a challenging subset of coronary artery disease (CAD). They are clinically associated with patients who are older, frailer, and with multi-morbidities, and angiographically with increased tortuosity and coronary artery calcification. Combined rotational (RA) excimer laser coronary atherectomy (ELCA), or RASER, may facilitate stent delivery and deployment in non-crossable, non-dilatable severely calcified lesions. In this study, we assessed preliminary safety and efficacy of the RASER hybrid technique. RASER feasible percutaneous coronary intervention (PCI) procedures performed at a large tertiary hospital in the northeast of England were retrospectively analyzed from September 1, 2008, to February 28, 2022. Major endpoints were in-hospital death from any cause, as well as procedural and angiographic success, defined by stent delivery with less than 50% residual stenosis and without clinical or angiographic complications, respectively. From 74 unique cases, there were 28 RASER, 24 ELCA/RA, 16 balloon angioplasty ± stenting, and 6 medically treated patients. In-hospital mortality rate was 5.2%, including 1 ELCA- and 3 RASER-treated patients. Successful stent delivery was achieved in significantly more RASER-treated patients compared to ELCA/RA- or balloon-treated patients: 96.4% (27/28), 25% (6/24), and 31.3% (5/16) respectively (P less than .001). In our retrospective, single-center study, patients with CAD who were deemed appropriate for RASER PCI had a high peri-procedural mortality rate. In this context, adjunctive RASER therapy provides acceptable safety and efficacy as a bailout strategy, with at least 3 out of 5 patients achieving satisfactory procedural and angiographic results. Randomized controlled trials are needed to comprehensively compare the clinical outcomes of high-risk RASER PCI vs conservative medical therapy.

Complex High-Risk Percutaneous Coronary Intervention Types, Trends, and Outcomes in Nonsurgical Centres

BackgroundLimited data are available on complex high-risk percutaneous coronary intervention (CHiP) trends and outcomes in nonsurgical centres (NSCs), particularly in health care systems where most centres are NSCs. MethodsUsing data from a national registry, we studied the characteristics and outcomes of CHiP procedures performed for stable angina from 2006 to 2017 according to the presence or absence of on-site surgical cover. Multivariate regression analyses and propensity score matching were used to determine risks for in-hospital death, major bleeding, and major cardiovascular or cerebral events (MACCE). ResultsOut of 134,730 CHiP procedures, 42,433 (31.5%) were performed in NSCs, increasing from 12.5% in 2006 to 42% in 2017. Compared with surgical centres (SCs), patients who had a CHiP procedure undertaken in NSCs were, on average, 2.4 years older and had a greater prevalence of cardiovascular risks. Common CHiP procedures performed in NSCs included poor left ventricular function (41.6%), chronic renal failure (38.8%), and chronic total occlusion percutaneous coronary intervention (31.1%). NSC-based CHiP is associated with lower odds of mortality (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI] 0.5-0.8) and major bleeding (aOR 0.7, 95% CI 0.6-0.8). In both groups, MACCE odds were similar (aOR 1.0, 95% CI 0.9-1.1). ConclusionsCHiP numbers have steadily increased in NSCs. NSC patients were older and had a higher prevalence of cardiovascular risks than SC patients. Mortality and major bleeding odds were significantly lower in those cases undertaken in NSCs, although MACCE odds were not different between the groups.