Prophylactic ECMO Support during Elective Coronary Percutaneous Interventions in High-Risk Patients: A Single-Center Experience.

Introduction: Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions. Methods: This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success. Results: Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis. Conclusions: Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery.

Retrograde CTO-PCI Using an Internal Thoracic Bypass Graft Segment in a Patient with Acute Inferior ST-Elevation Myocardial Infarction and Cardiogenic Shock.

Background: Percutaneous coronary intervention (PCI) of the "culprit" artery is the recommended mechanical reperfusion strategy in the setting of ST-segment elevation myocardial infarction (STEMI). As PCI of bypass grafts may be associated with higher risks and lower procedural success rates, in patients with a history of previous coronary artery surgery, PCI directed at revascularization of the native vessels should be considered, but this may be difficult in the setting of a chronically occluded artery. Case Presentation: A patient with a history of multivessel coronary artery disease and a chronic total occlusion (CTO) of the right coronary artery (RCA) requiring arterial bypass surgery, presented with an acute inferior STEMI and cardiogenic shock. It was felt that shock was caused by the acute thrombotic occlusion of a right internal thoracic artery (RITA) bypass graft that had been sequentially anastomosed to the left circumflex (LCx) and right coronary arteries. Despite initiation of extracorporeal membrane oxygenation (ECMO), the patient remained in refractory shock and acute revascularization of the right coronary artery was performed through the RITA bypass segment using antegrade access to the graft through the LCx and then a retrograde approach to open a CTO of the RCA. After successful revascularization, the patient was successfully weaned from ECMO. Over 12 months of follow-up, the patient did well and was documented to have improved left ventricular systolic function. Conclusion: This report is the first to document the successful use of a retrograde approach through an arterial graft segment to revascularize a chronic total occlusion in the setting of acute STEMI and cardiogenic shock.

RailTracking: A Novel Technique to Overcome Difficult Anatomy During Transradial Approach.

OBJECTIVE: We aim to investigate the safety and efficacy of a new technique, "RailTracking," in the management of challenging transradial routes during percutaneous coronary interventions (PCI). BACKGROUND: The transradial access (TRA) currently represents the access site of choice in PCI, but complex anatomy could lead to complications and access-site crossover. The assisted-tracking techniques described in the past (such as balloon-assisted tracking and pigtail-assisted tracking) are based on the concept of a "guiding tapered tip" to improve trackability. The RailTracking technique creates a tapered catheter tip using a dedicated device. METHODS: We collected patient data from January 2021 to January 2022 in 2 high-volume centers using the RailTracking technique as a bail-out solution. A prospective analysis of the anatomical characteristics and outcomes of the study population was performed. RESULTS: Seventy-seven patients were included in the study. All patients presented with challenging anatomies; 35.1% of the patients (n = 27) had small radial arteries, 19.5% (n = 15) had significant radial tortuosity, 2.6% (n = 2) had significant brachial tortuosity, 2.6% (n = 2) had subclavian tortuosity, and 1.29% (n = 1) had a critical subclavian lesion. In addition, 38.9% presented with severe radial spasm. The procedural success rate of the RailTracking technique was 98.7% (76/77 patients). The only case of failure presented with calcifications and a critical lesion in the subclavian artery. However, no periprocedural vascular complications occurred. This new technique appears safe, with a radial artery occlusion rate of 3.89% (n = 3) at 1-month follow-up. CONCLUSION: The new RailTracking technique improves catheter crossing in challenging anatomies and seems safe and effective in cases of failure with currently available approaches.

Acute Coronary Syndrome Mimicking Takotsubo Cardiomyopathy or Takotsubo Cardiomyopathy Mimicking Acute Coronary Syndrome?

A healthy 66-year-old female presented to the emergency department with acute chest pain, T-wave inversion in the anterior leads, and elevated troponin-I. Coronary angiography showed a stenosis in the midportion of the left anterior descending coronary artery (LAD), which did not wrap the left ventricle (LV) apex. LV angiography demonstrated a large LV apical akinetic systolic ballooning with a 45% ejection fraction. Fractional flow reserve (FFR) of LAD lesion was 0.71. Percutaneous intervention was performed. At six months, transthoracic echocardiography was normal. Fifteen months later, the patient presented with chest pain and a small rise in troponin-I. Coronary angiogram was unchanged. Repeat FFR in distal LAD was 0.86 and left ventriculography was normal. Diagnostic criteria for Takotsubo cardiomyopathy (TTC) require the absence of obstructive coronary artery disease. In the present case, TTC was highly suspected on the basis of typical LV apex ballooning. However, significant ischemia in the same territory was demonstrated by positive FFR, which could not be falsely positive in this context. Current TTC diagnostic criteria increase specificity for diagnosing TTC. This case reminds us that it is at the price of reduced sensitivity, since there is no reason to believe that coronary lesions may protect from TTC.