Direct Comparison of Percutaneous Circulatory Support Systems in Specific Hemodynamic Conditions in a Porcine Model

Abstract

Background-Several percutaneous circulatory support systems have been recently introduced into clinical practice for the treatment of cardiogenic shock or refractory nontolerated ventricular tachycardia, in support of high-risk catheter interventions and, occasionally, cardiopulmonary resuscitation. To date, however, a direct comparison of the available systems has not been performed. Methods and Results-Adult female pigs (weight 50-60 kg) were used throughout the experiment. Under deep anesthesia and mechanical ventilation, 3 percutaneous circulatory support systems were compared: (1) right atrium-aorta, extracorporeal membrane oxygenation (n=4); (2) left atrium-aorta, TandemHeart system (n=4); (3) left ventricle-aorta, Impella 2.5 system (n=4), and (4) left ventricle-aorta with norepinephrine at 0.1 µg/kg per minute (n=4). Hemodynamic efficacy (mean arterial pressure) was measured at 3 specific conditions: ventricular pacing at 200 and 300 beats per minute, and ventricular fibrillation. Although no or only nonsignificant differences were found among the systems at ventricular pacing of 200 and 300 beats per minute, under ventricular fibrillation, the right atrium-aorta system was significantly the most efficacious, followed by the left atrium-aorta system and the left ventricle-aorta system (P<0.001). However, the left ventricle-aorta system with norepinephrine still maintained mean arterial pressure comparable with the left atrium-aorta system. Conclusions-Differences were seen in the hemodynamic efficacy of available percutaneous circulatory support systems, particularly under the most severe hemodynamic condition, ventricular fibrillation. (Circ Arrhythm Electrophysiol. 2012;5:1202-1206.)

Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation

“…In agreement with the experimental work by Ostadal et al, 21 ECMO proved uniformly effective in providing a cardiac output to tolerate any induced arrhythmia, without impairing the possibility of multiple accesses to the left ventricle, allowing extensive endo-epicardial mapping free from electromagnetic interferences. The increased complexity of the ECMO setup (need for a Perfusionist) is largely rewarded by a superior method of hemodynamic support and by improved safety during the procedure.…”

Prophylactic mechanical hemodynamic support for catheter ablation of VT: locking the barn door before the horse has bolted

“…The study endpoint was maintenance of a target mean arterial pressure (MAP) of 70-80 mmHg. With ventricular pacing at 200 bpm, no difference in mean arterial pressure was observed between the three MHS systems; however, with ventricular pacing at [4] 300 bpm and during sustained VF, only ECMO support was able to maintain the target MAP, with the lowest efficacy being observed with the Impella TM device [8]. Therefore, whether the results reported by Mathuria et al can be generalized also to patients undergoing VA-ECMO support warrant further investigation.…”

“…Direct clinical comparative studies between different mechanical support devices are lacking, although some pre-clinical data exist. Ostadal et al compared the hemodynamic responses to sustained VF or rapid ventricular pacing (200 and 300 bpm) with VA-ECMO, the Impella TM and TandemHeart TM in a pig model [8]. The study endpoint was maintenance of a target mean arterial pressure (MAP) of 70-80 mmHg.…”

2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American heart assocation, the cardiological society of India, and sociedad latino Americana de cardiologia intervencion; Affirmation of value by the canadian association of interventional cardiology–association canadienne de cardiologie d'intervention)

“…Not infrequently LV contraction virtually ceases and perfusion is pumpdependent with a flat mean arterial pressure curve. Ventricular tachycardia or fibrillation usually but not always renders LVADs ineffective due to right ventricular failure (RVF) [49].…”

“…Whether the Impella CP further reduces native left ventricular stroke work and wall stress at comparable flow rates to the TandemHeart based on device inflow location is unknown. Similar to the TandemHeart, adequate RV function or concomitant RVAD is necessary to maintain LV preload and hemodynamic support during biventricular failure or unstable ventricular arrhythmias [49].…”