Post-Closure Technique to Reduce Vascular Complications Related to Impella CP.

BACKGROUND: Use of percutaneous mechanical circulatory support has grown exponentially. Vascular complications remain a growing concern and best practices for device removal do not exist. We describe a novel post-closure technique for the next generation Impella CP removal and immediate hemostasis. METHODS: This study is a single center, retrospective, exploratory analysis of 11 consecutive patients receiving an Impella CP for either high-risk PCI or cardiogenic shock and then referred for post-closure compared to 20 patients receiving manual compression for Impella CP removal between 2017 and 2019. RESULTS: Mean age range was 62.7-65.4 years and 50-65% male between groups. Average duration of Impella CP treatment ranged from 3.4 to 5.2 days. Patients referred for post-closure had significantly lower rates of all-cause adverse vascular events (0% versus 40%; n = 0/11 versus n = 8/20; p = 0.01). There was no significant difference in BARC 3 or greater bleeding, transfusion requirement, hospitalization duration or intensive care duration between removal strategies. CONCLUSION: The novel post-closure technique may significantly reduce vascular complications associated with device removal and may improve clinical outcomes for these critically ill patients.

Successful Rescue Intervention of Internal Mammary Artery Anastomotic Site Acute Graft Failure With Direct New Generation Covered Stenting.

Acute, perioperative myocardial infarction (MI) from acute left internal mammary artery (LIMA) to left anterior descending (LAD) graft failure immediately following coronary artery bypass grafting (CABG) surgery is associated with significantly increased in-hospital mortality. The leading etiology of such acute graft failure is acute thrombosis, dissection, spasm, anastomosis failure or no-reflow phenomenon. Repeat bypass surgery carries incremental risk and may not be feasible in hemodynamically unstable patients. Traditional percutaneous coronary intervention (PCI), with or without stent placement is sometimes used in such cases; however, graft anatomy and lesion location increase procedural complexity and challenge technical feasibility. This is particularly true of the LIMA to LAD graft anastomosis, where PCI carries the risk of anastomotic site perforation or avulsion. Therefore, the best revascularization strategy for such a lesion involving the LIMA to LAD graft anastomosis in the immediate perioperative period remains unknown. We present a case of 75-year-old male who suffered an acute MI complicated by cardiogenic shock less than 24 h after two-vessel CABG. Selective angiography revealed acute LIMA to LAD anastomotic site closure, posing a risk for perforation if treated with traditional angioplasty or stenting. We successfully performed rescue PCI, by directly deploying a PK Papyrus covered stent (Biotronik, Berlin, Germany) across the anastomosis. Our case report describes the upfront (rather than a bail out) use of the new covered stent as a novel revascularization strategy to treat "perforation prone" LIMA to LAD anastomotic site acute graft failure.

Right Atrial Pressure Is Associated With Outcomes in Patient With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support.

Background: We describe the association between longitudinal hemodynamic changes and clinical outcomes in patients with cardiogenic shock (CS) receiving acute mechanical circulatory support devices (AMCS) at a single center. We hypothesized that improved right atrial pressure is associated with better survival in CS. Methods: Retrospective analysis of patients from Tufts Medical Center that received AMCS for CS. Baseline characteristics and invasive hemodynamics were collected, analyzed, and correlated against outcomes. Hemodynamics were recorded at different time intervals during index admission [pre-AMCS, 24 h after AMCS (post AMCS), and last available set of hemodynamics (final-AMCS)]. Logistic regression was performed to determine variables associated with in-hospital mortality. Results: A total of 76 patients had longitudinal hemodynamics available. In hospital mortality occurred in 46% of the cohort. Mean baseline right atrial pressure (RAP) was significantly higher among non-survivors vs. survivors (19.5+6.6 vs. 16.4+5.3 mmHg). Change in right atrial pressure from baseline to before device removal (ΔRA:final AMCS-pre AMCS) was significantly different between survivors and non survivors (-6.5 ± 6.9 mmHg vs. -2.5 ± 6.2 mmHg p = 0.03). Unadjusted logistic regression revealed baseline RAP (OR: 1.1 95% CI: 1.0-1.2), 24 h post device implant RAP (OR: 1.3 95% CI: 1.1-1.4), and final RAP (OR: 1.3 95% CI: 1.1-1.5) to be significant predictors of in-hospital mortality. In a multivariate logistic regression baseline RAP was no longer significantly associated with mortality in the overall cohort, while 24 h (OR: 1.26 95% CI: 1.1-1.5) and final RAP (OR: 1.3 95% CI: 1.1-1.6) remained statistically significant. Conclusion: We report a novel retrospective analysis of hemodynamic changes in patients with CS receiving AMCS. Our findings identify the potential importance of venous congestion as a prognostic marker of mortality. Furthermore, early decongestion or reduced RA pressure is associated with better survival in these critically ill CS patients. These observations suggest the need for further study in larger retrospective and prospective cohorts of patients with varying degrees of CS severity.

Single stick access using a VA-ECMO arterial return cannula for coronary intervention in cardiogenic shock.

Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is growing exponentially for cardiogenic shock and cardiac arrest, and many of these patients require percutaneous coronary intervention (PCI). In some cases, radial arterial access may not feasible among patients with peripheral vascular disease or if larger diameter guide catheters are required. Further, VA-ECMO is commonly used in combination with an intra-aortic balloon pump or Impella, thereby limiting vascular access options and increasing the risk of vascular complications including bleeding and limb ischemia. For these reasons, new approaches to perform PCI without the need for an additional arterial puncture are required. We describe a case of a 70-year-old man with cardiogenic shock referred for high-risk PCI while supported with VA-ECMO and an Impella CP and illustrate a novel method for single-stick access for PCI through the return cannula of the VA-ECMO circuit.

Transaxillary Intra-Aortic Balloon Pump Deployment Through a Novel Braided Sheath for Advanced Heart Failure Patients Requiring an Extended Duration of Temporary Circulatory Support.

For decompensated advanced heart failure patients, the intra-aortic balloon pump (IABP) is a commonly used mechanical circulatory support (MCS) device used to support pharmacotherapy-refractory myopaths. In the United States, the heart allocation policy was revised in 2018, placing patients who may receive a clinically indicated temporary MCS device, like an IABP, at elevated medical urgency on the transplantation waiting list. Percutaneous transaxillary IABP delivery for the decompensated advanced heart failure patient is a safe, tolerable and efficacious alternative to traditional transfemoral deployment, and allows for ambulation and meaningful physical therapy engagement in the patient who may require an extended duration of support awaiting advanced therapies. We present two cases of percutaneous transaxillary IABP delivery via the Super Arrow-Flex braided sheath (Teleflex, Morrisville, NC) in advanced heart failure patients. The Super Arrow-Flex Sheath is a braided, durable, non-kinking conduit that can negotiate tortuous vascularity while maintaining its internal integrity; transaxillary IABP delivery through this sheath offers the patient a wide latitude of ipsilateral upper extremity movement and ambulation with minimal risk of damage to the IABP catheter. The Super Arrow-Flex sheath may improve transaxillary IABP security, durability and longevity in the advanced heart failure population for whom long-term IABP is anticipated.

Deployment of acute mechanical circulatory support devices via the axillary artery.

Introduction: Use of acute mechanical circulatory support (MCS) devices for high-risk cardiac intervention, cardiogenic shock, and advanced heart failure is growing. Alternate vascular access options for these devices remains a clinical challenge. Building on experience from trans-aortic valve replacement procedures, the axillary artery is becoming a common access route for acute MCS and represents an important advance in the development of acute MCS technologies. Areas covered: Authors review the clinical data and technical aspect of acute MCS deployment via the axillary artery. Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation. In this review, we discuss the deployment, technical issues and hemostasis regarding the use of intraaortic balloon pump, specifically, axillary intraaortic balloon pumps, trans-valvular left ventricular Impella pumps and arterial outflow of VA-ECMO. Expert opinion: Vascular comorbidities or device design may limit the traditional iliofemoral access route for acute mechanical circulatory support devices. Large bore access for the deployment of these devices through the axillary artery is feasible and safe when appropriate vascular access and closure techniques are used.

Counterpulsation requires pulsation: IABP use in patients with heart failure without acute MI.

Limited data exploring the utility of IABPs in shock without acute myocardial infarction exist. Counterpulsation pumps depend on native LV contractile function. Hemodynamic monitoring with a pulmonary artery catheter should help guide management of the cardiogenic shock patient. More studies are required to identify the optimal patient population and hemodynamic parameters best suited for IABP therapy.

Arrhythmias in a long-term adult survivor with uncorrected tetralogy of Fallot: Case report and review of the literature.

We present a case of a middle-aged adult with uncorrected Tetralogy of Fallot (TOF) with pulmonary atresia who developed symptomatic supraventricular and ventricular arrhythmias. The lack of data regarding management of electrical and other complications in adults with uncorrected TOF is highlighted and emphasizes the need for a registry to better understand the medical management of long-standing adult survivors.