1. Percutaneous Mechanical Circulatory Support Devices
From Guidelines to Practice
Moderator
Deepak L. Bhatt, MD, MPH
Professor of Medicine
Harvard Medical School
Executive Director of Interventional Cardiovascular Programs
Brigham and Women's Hospital Heart and Vascular Center
Boston, Massachusetts
Title Slide Layout

2. Panelists Atman P. Shah, MD Simon R. Redwood, MBBS, MD
Associate Professor of Medicine
Clinical Director, Coronary Care Unit
Co-Director, Adult Cardiac Catheterization Laboratory
University of Chicago Medicine
Chicago, Illinois
Panelists Layout (Title slide layout)
Simon R. Redwood, MBBS, MD
Professor of Interventional Cardiology
St Thomas Hospital
King’s College London London, United Kingdom

3. Case Presentation 57-year-old man presents with an anterior STEMI
PCI to LAD undertaken -- unable to reopen vessel despite prolonged attempt
Persisting ST elevation at the end of case
BP 110/60 mm Hg
Transferred to CCU at 6 pm
Clinical deterioration by the following morning
Oliguric
Diaphoretic
Cool peripheries
Lactate 4
Persisting ST elevation
BP 120/80 mm Hg
ECHO -- poor EF -- 10%
Transferred to cath lab for hemodynamic support in view of (incipient) cardiogenic shock

4. Presenting ECG
Courtesy of Simon R. Redwood, MBBS, MD.

5. Postprocedure ECG
Courtesy of Simon R. Redwood, MBBS, MD.

6. Stabilization After IABP Implantation
IABP 1:1; 2 min following deployment
IABP 1:1; 15 min following deployment
Courtesy of Simon R. Redwood, MBBS, MD.

7. Pulmonary Artery Pressure
PAP; Pre-IABP - Mean 34
PAP; 2-min Post-IABP - Mean 27
Courtesy of Simon R. Redwood, MBBS, MD.

8. OUTCOME Pain and ST elevation settled over next 2 hours
Lactate normalized
IABP weaned 72 hours later
Underwent successful CABG day 6
Uncomplicated recovery, post-CABG EF 25%

9. Case Key Points
IABPs are most useful in patients who have persistent ischemia
Routine use of IABPs does not provide an overall benefit
Careful selection of eligible patients who have persistent ischemia can yield dramatic and life- saving results

10. Hemodynamic Effects of IABP
Increases diastolic blood pressure
Decreases afterload
Decreases myocardial oxygen consumption
Increases coronary artery perfusion
Modestly enhances cardiac output
Modest ventricular unloading
Increases mean arterial pressure and coronary blood flow
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

11. Options for Mechanical Cardiopulmonary Support
IABP
Impella®
TandemHeart™
ECMO (Extracorporeal membrane oxygenation)

12. 2013 ACCF/AHA Guideline for the Management of STEMI
IIA Recommendation (Level of Evidence: B)
“The use of IABP can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy”
O’Gara PT, et al. Circulation 2013;127:e362-e425.

13. Cost-Effectiveness
Significant upfront cost of all the devices that many hospitals discourage
Which device provides the best clinical utility?
Prospect for a prolonged clinical benefit?
What is an acceptable cost?

14. Possible Indications for Mechanical Circulatory Support Devices
Complications of AMI
Severe heart failure in the setting of nonischemic cardiomyopathy
Acute cardiac allograft failure
Posttransplant RV failure
Patients slow to wean from cardiopulmonary bypass following heart surgery
Refractory arrhythmias
Prophylactic use for high-risk PCI
High-risk or complex ablation of ventricular tachycardia
High-risk percutaneous valve interventions
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

15. Balancing the Issue of Cost Selecting the Right Device for the Right Patient
Many factors to consider, including
recent drop in blood pressure?
cardiac arrest patient?
cardiogenic shock?
high-risk PCI?
age of the patient
risk factors EF
myocarditis?
structural heart complication?
do they need oxygenation?

16. Hemodynamic Support for the Cardiac Arrest Survivor
Start with IABP
Lower cost
Good effectiveness
Quickest and most familiar way to obtain some degree of hemodynamic stabilization, especially in the setting of AMI with pump failure
Step up to more supportive devices if patients do not stabilize
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

17. Impella® Minimizes or eliminates pressor use
Reduces myocardial oxygen demand
Improves systemic perfusion, thereby avoiding systemic shock
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

18. Vasopressors vs Support Devices
Consider any ongoing ischemia and the potential effect of increasing myocardial oxygen
If the patient is not doing well on 1 IV vasopressor consider increasing the level of support to MCS
Use of multiple pressors potentially increase the risk of arrhythmias

19. ECMO
Provides cardiopulmonary support for patients whose heart and lungs can no longer provide adequate physiologic support
veno-veno for oxygenation only
veno-arterial for oxygenation and circulatory support
In the setting of interventional cardiology and PCI not used as a first-line agent
Using ECMO with another device such as Impella or IABP may help in reducing afterload
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

20. TandemHeart™
Pumps blood extracorporeally from the left atrium (LA) to the iliofemoral arterial system pump contribute flow to the aorta simultaneously (thereby working in parallel, or tandem)
The redirection of blood from the LA reduces LV preload, LV workload, filling pressures, wall stress, and myocardial oxygen demand
The increase in arterial blood pressure and cardiac output supports systemic perfusion
Expertise with transseptal puncture is required
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

21. MCS for High-Risk PCI
Patient With Left Main, Last Remaining Conduit, or Severe Multivessel Disease
Normal or mildly reduced left ventricular function
Severe left ventricular dysfunction (EF < 35%) or recent decompensated heart failure
Anticipated Noncomplex PCI
None
IABP/Impella® as backup
Anticipated Technically Challenging or Prolonged PCI
IABP/Impella as backup
Impella® or TandemHeart™, choice dependent upon vascular anatomy, local expertise, and availability. ECMO for concomitant hypoxemia or RV failure.
A suggested schema for use of support devices for high-risk PCI based upon clinical and anatomic circumstances. The greater the likelihood of hemodynamic compromise or collapse the greater the potential benefit of MCS.
Rihal CS, et al. J Am Coll Cardiol. 2015;65:e7-e26.

22. Summary
Routine use of hemodynamic support device is probably not necessary
Individualize care to each patient
Making early decision between device vs pressor and which device is important
MCS devices have different characteristics
The IABP is very good at improving coronary flow in the presence of persistent ischemia and has afterload reduction properties
Impella® provides more support than the IABP at L/min. It is used when patients are at more extreme risk or at the extreme end of the hemodynamics spectrum. Actively unloads the LV.

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