Support In Percutaneous Coronary Intervention Research Articles

Microaxial circulatory support for percutaneous coronary intervention: A systematic review and meta-analysis.

Microaxial circulatory support devices have been used to support patients treated with percutaneous coronary intervention (PCI) for acute myocardial infarction complicated by cardiogenic shock (AMICS). The purpose of this systematic review and meta-analysis was to pool and analyze the existing evidence on the baseline characteristics, periprocedural data, and outcomes of microaxial support before and after PCI in AMICS. An electronic database search was performed to identify all cohort studies on Impella and PCI for cardiogenic shock in the English language. A total of five articles comprising 543 patients were included. These patients received microaxial support either before (pre-PCI) or after (post-PCI) undergoing PCI. Comparative analyses were done between both groups. The mean patient age was 66 years [95% Confidence Interval (58-74)], and 22% (89/396) of patients were female. ST-elevation myocardial infarctions (MI)comprised64% (44-80) of MIs and 50% (44-56) of MIs involved the left anterior descending artery. The mean number of diseased vessels was 2.21 (1.62-2.80). The mean left ventricular ejection fraction was 31% (23.4-38.6). The mean arterial pressure was 66.3 mm Hg (54.1-78.5). Mean serum lactate [6.1 mmol/L (3.3-8.9)] and serum creatinine [1.4mg/dl (1.0-1.7)] were similar between groups. 30-day mortality was lower in the pre-PCI group [41% (34%-49%)] compared to the post-PCI group [61% (42%-77%), p< 0.01]. Pooled Kaplan-Meier analysis showed better early survival in the pre-PCI group (p< 0.001). Patients presenting with AMICS were similar at baseline in both pre-PCI and post-PCI groups. Nevertheless, pre-PCI group showed better early survival compared to post-PCI group.

Reducing stray radiation with a novel detachable lead arm support in percutaneous coronary intervention.

BackgroundPlacing radioprotective devices near patients reduces stray radiation during percutaneous coronary intervention (PCI), a promising technique for treating coronary artery disease. Therefore, lead arm support may effectively reduce occupational radiation dose to cardiologists.PurposeWe aimed to estimate the reduction of stray radiation using a novel detachable lead arm support (DLAS) in PCI.Materials and methodsA dedicated cardiovascular angiography system was equipped with the conventional 0.5‐mm lead curtain suspended from the table side rail. The DLAS was developed using an L‐shaped acrylic board and detachable water‐resistant covers encasing the 0.5‐, 0.75‐, or 1.0‐mm lead. The DLAS was placed adjacent to a female anthropomorphic phantom lying on the examination tabletop at the patient entrance reference point. An ionization chamber survey meter was placed 100 cm away from the isocenter to emulate the cardiologist's position. Dose reduction using the L‐shaped acrylic board, DLAS, lead curtain, and their combination each was measured at five heights (80–160 cm in 20‐cm increments) when acquiring cardiac images of the patient phantom with 10 gantry angulations, typical for PCI.ResultsMedian dose reductions of stray radiation using the L‐shaped acrylic board were 9.0%, 8.8%, 12.4%, 12.3%, and 6.4% at 80‐, 100‐, 120‐, 140‐, and 160‐cm heights, respectively. Dose reduction using DLAS with a 0.5‐mm lead was almost identical to that using DLAS with 0.75‐ and 1.0‐mm leads; mean dose reductions using these three DLASs increased to 16.2%, 45.1%, 66.0%, 64.2%, and 43.0%, respectively. Similarly, dose reductions using the conventional lead curtain were 95.9%, 95.5%, 83.7%, 26.0%, and 19.6%, respectively. The combination of DLAS with 0.5‐mm lead and lead curtain could increase dose reductions to 96.0%, 95.8%, 93.8%, 71.1%, and 47.1%, respectively.ConclusionsDLAS reduces stray radiation at 120‐, 140‐, and 160‐cm heights, where the conventional lead curtain provides insufficient protection.

Microaxial Circulatory Support for Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

<h3>Purpose</h3> Microaxial circulatory support can facilitate percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction with cardiogenic shock (AMICS). While proper timing of support is important, data are lacking to inform a standardized approach. We sought to pool existing evidence and compare outcomes of microaxial support based on its initiation before or after PCI. <h3>Methods</h3> Electronic search identified adult patients with AMICS undergoing PCI who received Impella 2.5, CP, or 5.0 support. Cohort-level data for 543 patients from 5 studies were extracted and analyzed. Patients were categorized as pre-PCI (Impella before PCI) or post-PCI (Impella after PCI) groups. Individual Kaplan-Meier survival curves were digitized and combined to analyze pooled survival. <h3>Results</h3> Mean patient age was 66 (95% CI: 58-74) years with 23% (17-30%) being female. Pre-PCI group had a higher incidence of previous stroke or transient ischemic attack [14% (6-28%) vs. 6% (3-14%), p = 0.02] and a trend toward higher incidence of diabetes [44% (22-69%) vs. 27% (13-48%), p = 0.08]. Mean left ventricular ejection fraction [pre-PCI: 29.5% (18.2-40.8%) vs. post-PCI: 32.3% (21.9-42.6%), p = 0.72] was similar between groups. Mean serum lactate was 6.5 (2.3-10.7) mmol/L in pre-PCI group and 5.7 (2.0-9.50) mmol/L in post-PCI group (p = 0.8). Pre-PCI group's incidence of cardiac arrest before Impella was 56% (4-98%) compared to 67% (8-98%) for post PCI-group (p = 0.76). Total duration of support was 1.6 (0-3.7) and 1.3 (0-3.3) days in pre-PCI and post-PCI groups, respectively (p = 0.87). 30-day mortality was lower in pre-PCI group [41% (34-49%) vs. 61% (42-77%), p < 0.01]. Pooled Kaplan-Meier analysis showed better early survival (log rank: p < 0.001) in pre-PCI group (Figure). <h3>Conclusion</h3> Timing of microaxial support initiation may reflect higher perceived risk in pre-PCI patients and higher acuity in post-PCI patients. Early survival appears to be better when microaxial support is initiated pre-PCI.

Ten-year trends, predictors and outcomes of mechanical circulatory support in percutaneous coronary intervention for acute myocardial infarction with cardiogenic shock.

There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS. Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p<0.001) and greater resource utilisation. IABP-assisted PCI had lower in-hospital mortality and lesser resource utilisation compared to pLVAD/ECMO. MCS-assisted PCI identified a sicker AMI-CS cohort. There was a decrease in IABP and an increase in pLVAD/ECMO.

Temporary percutaneous ventricular assist devices for cardiogenic shock and high-risk percutaneous coronary intervention: a systematic literature review

Percutaneous ventricular assist devices (pVADs) are frequently used for the treatment of patients with cardiogenic shock (CS) due to acute myocardial infarction (AMI) and as a support in percutaneous coronary intervention (PCI) for high-risk patients. CS is a clinical condition characterized by inadequate tissue perfusion due to cardiac dysfunction and for 80% of cases it is caused by AMI with left ventricular insufficiency. CS is responsible for about 50% of deaths in patients with myocardial infarction. Usually, PCIs do not require hemodynamic support, which could be however necessary in patients undergoing high-risk PCI. Presently, available pVADs in Europe are Impella 2.5, Impella CP, HeartMate PHP, TandemHeart, PulseCath iVAC2L. The aim of this review is to evaluate the efficacy and safety of pVADs in patients with refractory CS complicating AMI or undergoing high-risk PCI. We systematically searched for randomized controlled trials (RCTs) and controlled observational studies in PubMed, Embase and PubMed CENTRAL databases until September 2018. We included studies comparing pVADs with intra-aortic balloon pumps (IABP) or medical therapy in patients with CS complicating AMI or undergoing high-risk PCI. Researchers independently assessed records' eligibility, inclusion and methodological quality of included studies. If possible, data of included studies was combined in a meta-analysis. Risk ratio (RR) and 95% confidence interval (CI) were calculated using a random effects model. Overall, 8 studies were included. Five studies (3 RCTs and 2 observational studies) evaluated pVADs in patients with SC complicating AMI. Meta-analyses showed that 30-day mortality did not differ between patients treated with pVADs and the control group (RR 1.05, 95% CI 0.84-1.31). However, risk of major bleeding was 2 times higher in patients treated with pVADs compared to controls. Three studies evaluated pVADs in patients undergoing high-risk PCI. Due to the lack of data, it was not possible to combine study results in a meta-analysis. One RCT reported no difference in 30- and 90-day mortality between patients randomized to Impella or IABP. Two non-randomized controlled studies reported no difference in terms of in-hospital all-cause mortality between the two groups. Our meta-analysis suggests similar results in terms of efficacy and safety between pVADs and control (IABP and medical therapy) for the treatment of patients with CS complicating AMI or undergoing high-risk PCI.

Use of Mechanical Circulatory Support in Percutaneous Coronary Intervention in the United States

Percutaneous ventricular assist devices (PVADs) and intraaortic balloon pump (IABP) are used to provide mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI). Contemporary trends in their utilization and impact on in-hospital mortality are not known. Using the National Inpatient Sample (2004 to 2012), we identified 5,031 patients who received a PVAD and 122,333 who received an IABP on the same day as PCI using International Classification of Diseases, Ninth Edition codes. Utilization of MCS increased from 1.3% of all PCIs in 2004 to 3.4% in 2012 (p trend <0.001), with increase in the use of both PVAD (<1/10,000 PCIs [2004 to 2007] to 38/10,000 [2012]) and IABP (132/10,000 PCIs [2004] to 299/10,000[2012] p <0.0001 for both). PVAD recipients were older (69 vs 65 years), more likely to have heart failure (68% vs 41%), chronic kidney disease (27% vs 11%, p <0.001 for all), and be admitted electively (30% vs 11%), but less likely to have acute myocardial infarction (52% vs 90%), cardiogenic shock (23% vs 50%), or need mechanical ventilation (16% vs 29%) compared with IABP recipients. Unadjusted in-hospital mortality was lower in PVAD compared with IABP recipients (12.8% vs 20.9%, p <0.001). However, in propensity-matched analyses (1:2), in-hospital mortality was similar in both groups (odds ratio 0.88, 95% confidence interval 0.70 to 1.09). In conclusion, there has been a marked increase in the utilization of MCS in patients undergoing PCI. Unadjusted mortality using PVADs is lower than IABP but may be due to their selective use in patients at lower risk. Randomized trials are necessary to establish their effectiveness in supporting high-risk PCI.

Abstract 114: Mechanical Circulatory Support in Percutaneous Coronary Intervention: A Propensity-matched Analysis

Introduction: Percutaneous ventricular assist devices (PVAD) and intra-aortic balloon pump (IABP) are used to provide mechanical circulatory support for high-risk percutaneous coronary intervention (PCI). Due to limited evidence from randomized controlled trials, we compared clinical outcomes between PVAD and IABP in PCI patients using a propensity-matched analysis. Methods: Adult patients who underwent PCI during 2004-2012 and also received either a PVAD or an IABP on the same day as PCI were identified in the National Inpatient Sample using ICD9 procedure codes. We compared in-hospital mortality for PVAD vs. IABP using a 1:2 propensity-matched analysis - both overall and in subgroups with cardiogenic shock, AMI without cardiogenic shock and no cardiogenic shock or AMI. Results: We identified 5031 patients who received a PVAD and 122,333 who received an IABP on the same day as PCI. Patients who received PVAD were older (69 vs 65 years), more likely to be men (74% vs 69%), admitted electively (30% vs 11%) but less likely to have AMI (52% vs 90%), cardiogenic shock (23% vs 50%), cardiac arrest (12% vs 25%) or need mechanical ventilation (16% vs 29%) compared to IABP patients (P&lt;0.001 for all). In contrast, prevalence of heart failure (68% vs 41%), valvular heart disease (22% vs 13%), chronic kidney disease (27% vs 11%), hypertension (71% vs 56%) and diabetes (46% vs 32%) was higher in PVAD recipients (P&lt;0.001 for all). Unadjusted in-hospital mortality in PVAD recipients was lower compared to IABP patients - both overall (12.8% vs 20.9%, P&lt;0.001) and in the cardiogenic shock subgroup (31% vs 38%, P=0.04) but was similar in patients without cardiogenic shock. After propensity-matching and successful balancing of covariates (figure) we found no difference in mortality in PVAD and IABP recipients (odds ratio [OR] 0.88, 95% CI 0.70-1.09). Our findings were also consistent among patients with cardiogenic shock (OR 1.37, 95% CI 0.99-1.90), AMI without cardiogenic shock (OR 0.72, 95% CI 0.46-1.14) and no cardiogenic shock or AMI (OR 0.54, 95% CI 0.27-1.06). Conclusion: The lower unadjusted mortality in patients undergoing PCI with PVAD support compared to IABP support may be due to selective use of PVADs in a lower risk population. Randomized trials are necessary to establish the clinical effectiveness of PVADs to support high-risk PCI.

Percutaneous Hemodynamic Support in PCI

Percutaneous coronary intervention (PCI) procedures are attempted with increasingly frequency in hemodynamically unstable, high-risk, and complex patients. Hemodynamic support can be advantageous in select patients presenting with acute myocardial infarction and cardiogenic shock. The need for hemodynamic support has recently shifted from patients with hemodynamic collapse to support of patients during high-risk complex PCI procedures during elective cases such as left main disease, multivessel disease, or low-flow heart failure. Currently, the three most common types of percutaneous hemodynamic support devices available in the United States are the intra-aortic balloon pump (IABP) and the left ventricular assist devices TandemHeart and Impella. Each of these devices has its advantages and disadvantages, and an understanding of the role each plays in various pathophysiologic conditions is necessary, as this will assist the practitioner in making the correct decision as to which device will optimize patient outcomes. Recent studies have called into question the need for certain devices in specific situations. However, ongoing clinical trials will provide further insight into the comparative advantages and disadvantages of each and whether one or more is beneficial over another in reducing cardiovascular events and mortality. With continued refinements in device technology, technique, and application, it is anticipated that percutaneous device-based procedures will continue to improve patient outcomes in the most critically ill and highest-risk patients.

Primary coronary angioplasty in a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva

We report a rare case of primary coronary angioplasty in a patient with acute myocardial infarction due to thrombotic occlusion of an anomalous right coronary artery arising from the left sinus of Valsalva. The non-invasive method of ischaemia localisation, such as ST-segment elevation on the electrocardiogram, was useful in identifying the infarct-related artery. A major factor was the selection of the guiding catheter to access the anomalous right coronary artery and also to obtain good angiographic visualisation and adequate support for percutaneous coronary intervention.