Use of Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention

Sandhu, Amneet; McCoy, Lisa A.; Negi, Smita; Hameed, Irfan; Atri, Prashant; Al’Aref, Subhi J.; Curtis, Jeptha P.; McNulty, Ed; Anderson, H. Vernon; Shroff, Adhir; Menegus, Mark; Swaminathan, Rajesh V.; Gurm, Hitinder S.; Messenger, John C.; Wang, Tracy; Bradley, Steven M

doi:10.1161/circulationaha.114.014451

Cited by 102 publications

(56 citation statements)

References 21 publications

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“…23,24 Recently, other percutaneous MCS devices have shown promise in the treatment of CS, but more data from randomized clinical trials are needed.…”

Section: 20mentioning

confidence: 99%

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Diepen¹,

Katz²,

Albert³

et al. 2017

Circulation

1,285

1,165

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Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities. Cardiogenic shock (CS) is a low-cardiac-output state resulting in life-threatening end-organ hypoperfusion and hypoxia.1,2 Acute myocardial infarction (MI) with left ventricular (LV) dysfunction remains the most frequent cause of CS. 1,3 Advances in reperfusion therapy have been associated with improvements in survival, but significant regional disparities in evidence-based care have been reported, and in-hospital mortality remains high (27%-51%).1,4-9 Management recommendations are distributed between disease-specific statements and guidelines, and a dedicated and comprehensive clinical resource in this area is lacking. Thus, consolidating the evidence to define contemporary best medical and surgical CS practices for both MI-associated CS and other types of CS may be an important step in knowledge translation to help attenuate disparities in evidence-based care.Regional systems of care coupled with treatment algorithms have improved survival in high-acuity time-sensitive conditions such as MI, out-of-hospital cardiac arrest (OHCA), and trauma.10-12 Applying a similar framework to CS management may lead to similar improvements in survival, and CS systems of care are emerging within existing regional cardiovascular emergency care networks; however, guidance from a national expert group on structure and systems of care has not been available. 13,14 Accordingly, the purposes of this American Heart Association (AHA) scientific statement on CS are to summarize our contemporary understanding of the epidemiology, pathophysiology, and in-hospital best care practices into a single clinical resource document; to suggest a stepwise management algorithm that integrates medical, surgical, and mechanical circulatory support (MCS) therapies; and to propose a Mission: Lifelinesupported pathway for the development of integrated regionalized CS systems of care. DEFINITION OF CSAcute cardiac hemodynamic instability may result from disorders that impair function of the myocardium, valves, conduction system, or pericardium, either in isolation HISTORICAL PERSPECTIVESBefore the routine use of early revascularization, MIassociated CS had an in-hospital mortality exceeding 80%. A registry trial of 250 patients with acute MI described the association between bedside physical examination (Killip classification) for the as...

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“…23,24 Recently, other percutaneous MCS devices have shown promise in the treatment of CS, but more data from randomized clinical trials are needed.…”

Section: 20mentioning

confidence: 99%

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Diepen¹,

Katz²,

Albert³

et al. 2017

Circulation

1,285

1,165

View full text Add to dashboard Cite

show abstract

“…We currently attempt to get at this information indirectly such as analyzing the use of short-term mechanical support circulatory devices from national databases such as the National Cardiovascular Data registry Cath PCI Registry or the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, which however are not designed to provide much guidance about highrisk PCI. [8][9][10] Similar to our experience with percutaneous valve therapies, high-risk PCI involves a multidisciplinary team approach. Many of the patients sent to our practice are turned down for coronary artery bypass grafting or repeat coronary artery bypass grafting by cardiac surgeons.…”

Section: Challengesmentioning

confidence: 94%

“…6 Currently, 2 FDA approved percutaneous ventricular assist devices, the Impella and the Tandem Heart, are available offering superior hemodynamic support compared with traditional intra-aortic balloon pump counterpulsation. 7,8 Both these devices present their own benefits and challenges, each requiring expertise in vascular access and deployment. Physician and support team expertise is also required to manage these devices during the PCI and in the postprocedural time period.…”

Section: Bassmentioning

confidence: 99%

High-Risk Percutaneous Coronary Interventions in Modern Day Clinical Practice

Bass

2015

Circ: Cardiovascular Interventions

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A t its inception, all percutaneous coronary interventions (PCI) were considered high risk. The initial US experience published by the National Heart, Lung, and Blood Institute Registry reported procedural success to be <60% and the need for emergent coronary bypass surgery occurring 6% of the time.1 It was mandatory to have a cardiothoracic surgeon immediately available and an operating room open and ready to go. These outcomes involving a far less complex, lower risk population compared with patients we currently treat would be completely unacceptable today. The evolution of coronary interventions has been remarkable during the past decades attributable to the refinement and development of new device technologies, imaging capabilities, adjunctive pharmacotherapies and the explosive growth in physician and catheterization laboratory team experience. This has resulted in a greatly expanded population who can now be treated by PCI, including sicker patients often with more complex anatomic lesions. Overall reported procedural success rates are now expected to approach 100% and complication rates continue to trend toward or <1%. With this history and in our current environment of expanding databases, public reporting, cost-sensitive resource use, and increased patient expectations, the concept and reality of high-risk PCI continues to evolve.First and foremost, it is helpful to differentiate complex PCI from high-risk PCI. The interventional cardiovascular community has spent a great deal of effort defining, classifying, and attempting to understand how to best treat patients presenting for complex PCI. The term complex PCI is a descriptor applied to patients presenting with complex, anatomic coronary lesions. These lesions may have a variety of defining characteristics such as severe calcification, extensive thrombotic burden, extreme tortuosity or length, or might be chronically, totally occluded. The lesion location might be located at a coronary bifurcation or in a degenerated saphenous venous bypass graft. Analysis derived from large registries have consistently demonstrated that PCI involving these anatomically complex lesions results in expected lower procedural success rates with an increased risk of procedural complications when compared with PCI of less anatomically complex coronary lesions. 2 We have successfully developed both the technology and interventional techniques to facilitate optimally treating these lesions.An example of a complex PCI might be a middle-aged male with normal left ventricular (LV) function and increasing angina presenting for PCI with a heavily calcified bifurcation lesion involving the left anterior descending-first diagonal bifurcation. This is indeed different from what should be considered as a high-risk PCI, which might involve the same angiographic lesion, but occurring in an elderly male with a chronically occluded right coronary artery and a severely decreased LV ejection fraction. Therefore, the approach, skill sets, and support systems required to do these interventi...

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“…8 Moreover, considerable concerns remain about the difficulty of PVAD insertion, concerns that include a prolonged implantation time, risk of limb ischemia, bleeding, and hemolysis, to say nothing of the considerable costs of these devices. 12 With these recent developments in mind, in this issue of Circulation, Sandhu et al 13 ). Among such patients with shock undergoing PCI, 54% received no mechanical support, 39% received IABP alone, 3.5% received other MCS, and another 3.6% received both IABP plus another MCS device.…”

Section: Article See P 1243mentioning

confidence: 99%

“…13 Several important limitations to the CathPCI registry data are worth noting, most of which the authors address. First, the broad classification of reduced cardiac index or hypotension used to defined shock in the study captures a heterogeneous group of patients with varying degrees of impairment.…”

Section: Article See P 1243mentioning

confidence: 99%

Finding Traction for Mechanical Circulatory Support During Coronary Interventions

Stewart

2015

Circulation

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Use of Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention

Abstract: In this large national registry, the use of IABP in the setting of PCI for cardiogenic shock decreased over time without a concurrent increase in O-MCS use. The probability of IABP and O-MCS use varied across hospitals, and the use of O-MCS was clustered at a small number of hospitals.

Cited by 102 publications

References 21 publications

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

High-Risk Percutaneous Coronary Interventions in Modern Day Clinical Practice

Finding Traction for Mechanical Circulatory Support During Coronary Interventions

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