Mechanical Pre-Conditioning With Acute Circulatory Support Before Reperfusion Limits Infarct Size in Acute Myocardial Infarction

Kapur, Navin K.; Qiao, Xiaoying; Paruchuri, Vikram; Morine, Kevin; Syed, Wajih; Dow, Sam; Shah, Nimish; Pandian, Natesa G.; Karas, Richard H.

doi:10.1016/j.jchf.2015.06.010

Cited by 101 publications

(79 citation statements)

References 22 publications

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“…The resulting decrease in LV pressures and volumes decreases cardiac workload (Figure 2B). 15,20 Since Impella is positioned in the LV, there are obvious contraindications including significant aortic valve disease, mechanical aortic valve and LV thrombus. 15,21 …”

Section: Circulatory Support Devicesmentioning

confidence: 99%

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Miller

Solomon

McAreavey

2017

Critical Care Medicine

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Objective To review temporary percutaneous mechanical circulatory support devices (pMCS) for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. Data Sources A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation (ECMO), Impella, and TandemHeart. Study Selection Selected publications included randomized controlled trial data and observational studies describing experience with pMCS in cardiogenic shock. Data Extraction Studies were chosen based on strength of association with and relevance to cardiogenic shock. Data synthesis Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump (IABP) counterpulsation. Now, several pMCS devices, including Impella®, TandemHeart™, and ECMO, are more accessible. Compared with IABP, Impella provides greater hemodynamic support, but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables, but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial ECMO offers the advantage of biventricular circulatory support and oxygenation but there are significant vascular complications. Comparative studies with ECMO have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of pMCS. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. Conclusions Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. While evidence is lacking and complications rates are high, improvements and experience with pMCS may offer the prospect of better outcomes.

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Section: Circulatory Support Devicesmentioning

confidence: 99%

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Miller

Solomon

McAreavey

2017

Critical Care Medicine

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“…The impact of Impella therapy on coronary flow and LV unloading were further confirmed by Sauren et al using a preclinical model of acute myocardial ischaemia 29. While animal models have demonstrated a reduction in myocardial demand through a shift in the PV loop downwards and left, reflecting reductions in both LVEDP and LVEDV (see figure 3),41 this has not been borne out in a clinical physiological study 44…”

Section: Direct LV Unloading – Impella and Heartmate Phpmentioning

confidence: 92%

“…The device is passed retrogradely across the aortic valve and unloads the LV directly, thereby increasing cardiac output, reducing myocardial oxygen consumption (by reducing both LV pressure and volume) and decreasing pulmonary capillary wedge pressure. Animal models of CS have shown improvements in many systemic haemodynamic parameters and LV unloading,39–41 and also reduced infarct size with the use of Impella 41 42. More recently, both preclinical and clinical data suggest that primarily unloading the LV before coronary reperfusion may reduce infarct size and improve both in-hospital and short-term mortality 41 43.…”

Section: Direct LV Unloading – Impella and Heartmate Phpmentioning

confidence: 99%

“…Animal models of CS have shown improvements in many systemic haemodynamic parameters and LV unloading,39–41 and also reduced infarct size with the use of Impella 41 42. More recently, both preclinical and clinical data suggest that primarily unloading the LV before coronary reperfusion may reduce infarct size and improve both in-hospital and short-term mortality 41 43. Remmelink et al 22 demonstrated that when autoregulation is intact, the Impella 2.5L has minimal impact on coronary flow in a group of patients undergoing high-risk PCI.…”

Section: Direct LV Unloading – Impella and Heartmate Phpmentioning

confidence: 99%

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Percutaneous mechanical circulatory support: current concepts and future directions

Briceno

Kapur

Perera

2016

Heart

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“…Although the intra-aortic balloon pump has traditionally been the most commonly used MCS platform, it provides only minimal augmentation of cardiac output (8) and has failed to significantly improve patient outcomes in a number of recent studies (9,10). These disappointing results have stimulated the development of more powerful percutaneous left ventricular (LV) assist devices that offer enhanced circulatory support, ventricular unloading, and even potential clinical utility in patients with acute myocardial ischemia in the absence of cardiogenic shock (11–13). …”

mentioning

confidence: 99%

Comparative Hemodynamic Effects of Contemporary Percutaneous Mechanical Circulatory Support Devices in a Porcine Model of Acute Myocardial Infarction

Weil¹,

Konecny²,

Suzuki³

et al. 2016

JACC: Cardiovascular Interventions

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OBJECTIVES The aim of this study was to directly compare the hemodynamic effects of 2 contemporary percutaneous mechanical circulatory support devices in a porcine model of acute myocardial infarction. BACKGROUND Percutaneous support devices offer the ability to unload the ischemic left ventricle, but the comparative hemodynamic effects of contemporary platforms are unclear. METHODS Yorkshire swine (mean weight 76 ± 2 kg; n = 7) were instrumented with a left ventricular (LV) pressure-volume (PV) catheter and subjected to a 2-h coronary occlusion. Hemodynamic parameters and PV-derived indexes of LV performance were assessed 30 min after reperfusion and during LV support with Impella CP (ICP) and TandemHeart devices (in randomized order) at comparable flow rates. RESULTS Myocardial infarction produced a rightward shift of the PV loop and increased LV end-diastolic pressure (from 9 ± 2 mmHg to 15 ± 2 mm Hg; p = 0.04). After reperfusion, both devices maintained aortic pressure, shifted the PV loop to the left, and decreased LV end-diastolic pressure (ICP vs. TandemHeart; 11 ± 1 mm Hg vs. 7 ± 4 mm Hg; p = 0.04). However, only TandemHeart elicited significant reductions in native LV stroke volume (from 75 ± 7 ml to 39 ± 7 ml; p < 0.01), dP/dtmax (from 988 ± 77 mm Hg/s to 626 ± 42 mm Hg/s; p < 0.01), stroke work (from 0.70 ± 0.03 J to 0.26 ± 0.05 J; p < 0.01), PV area (from 0.95 ± 0.11 J to 0.47 ± 0.10 J; p < 0.01), and pre-load-recruitable stroke work slope (from 41.7 ± 2.8 J/ml to 30.6 ± 3.9 J/ml; p = 0.05). CONCLUSIONS At comparable device flow rates, TandemHeart decreased LV pre-load, native LV stroke volume, and myocardial contractility to a greater degree than ICP. Reductions in load-independent indexes of LV performance indicate favorable effects on myocardial oxygen balance and support further study of TandemHeart in clinical scenarios requiring mechanical support in the setting of acute myocardial ischemia.

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Mechanical Pre-Conditioning With Acute Circulatory Support Before Reperfusion Limits Infarct Size in Acute Myocardial Infarction

Cited by 101 publications

References 22 publications

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Advanced Percutaneous Mechanical Circulatory Support Devices for Cardiogenic Shock

Percutaneous mechanical circulatory support: current concepts and future directions

Comparative Hemodynamic Effects of Contemporary Percutaneous Mechanical Circulatory Support Devices in a Porcine Model of Acute Myocardial Infarction

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