Nonemergent Percutaneous Coronary Intervention on an Unprotected Left Main Coronary Artery Supported with Impella® Heart Pump in Patients Ineligible for Surgical Revascularization

Abstract

Objectives. We sought to assess if ineligibility to coronary artery bypass grafting (CABG) constitutes a risk factor in patients who underwent a nonemergent unprotected left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with prophylactic Impella® heart pump support. Background. ULMCA PCI in patients not deemed eligible for CABG is associated with significantly worse outcomes compared to ULMCA PCI in eligible patients. Methods. Patients from the cVAD Registry and the PROTECT II trial who underwent a nonemergent ULMCA PCI were identified. We compared in-hospital mortality and major adverse cardiac and cerebrovascular event (MACCE) rates as well as 30-day survival and MACCE rates between CABG ineligible and CABG eligible patients. Results. A total of 331 patients were included (293 Impella 2.5®, 38 Impella CP®); 227 were ineligible for CABG and 104 were eligible. Baseline characteristics were remarkable for a trend toward higher rate of chronic obstructive pulmonary disease in the ineligible patients. In-hospital mortality (3.52% vs. 5.77%; p=0.383) and MACCE (6.61% vs. 7.69%; p=0.816) rates as well as 30-day survival (92.0% vs. 93.4%; Log-Rank p-value =0.781) and MACCE (88.1% vs. 90.1%; Log-Rank p-value=0.648) rates were not different between the two groups. Conclusions. The results of our study suggest that prophylactic Impella support appears to mitigate the risks inherent to surgical ineligibility in patients undergoing a nonemergent ULMCA PCI. Our results require further investigation.

Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology

“…36,40 The most common complications of Impella support in elective clinical scenarios were access site bleeding and hemolysis. 44,47,50,52 To prevent the latter, frequent echocardiographic control of the Impella position is advisablethe teardrop should be about 3.5 cm from the aortic valve annulus to ensure that the inflow is in the midventricular cavity according to the manufacturer's recommendation.…”

“…The most common complications of Impella support in elective clinical scenarios were access site bleeding and hemolysis. 44,47,50,52 To prevent the latter, frequent echocardiographic control of the Impella position is advisable—the teardrop should be about 3.5 cm from the aortic valve annulus to ensure that the inflow is in the midventricular cavity according to the manufacturer’s recommendation. Acute renal failure and pericardial effusion were reported in patients with Impella support during VT ablation, whereas the reported incidence of cardiac tamponade ranged up to 11%, occurring mostly in patients undergoing epicardial mapping and catheter ablation.…”

Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

“…56 A recent RCT and postmarketing study suggested more complete revascularization and lower short-and intermediate-term rates of major adverse cardiac and cerebrovascular events with hemodynamic support with Impella than with an intra-aortic balloon pump. 57,58 An RCT is expected to begin enrollment in 2021 comparing Impella to no hemodynamic support in patients undergoing high-risk PCI. 59…”

Turndown for coronary artery bypass surgery: Never say never to revascularization

“…Since left main interventions seem particularly problematic in patients turned down for surgery, one may consider prophylactic hemodynamic support. One publication of 331 unprotected left main interventions noted similar mortality and morbidity between surgically eligible and ineligible patients who were treated with prophylactic impella support 4 …”

“…One publication of 331 unprotected left main interventions noted similar mortality and morbidity between surgically eligible and ineligible patients who were treated with prophylactic impella support. 4 Most recently, the Outcomes of Surgically Ineligible Patients with Multivessel Coronary disease (OPTIMUM) Registry was reported but not yet published. 5 In this multicenter registry, 750 patients were turned down for surgery due to poor distal target/ conduit (19%), severe LV dysfunction/nonviable myocardium (17%), severe lung disease (10%), followed by frailty, advanced age and other factors.…”