Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock.

INTRODUCTION: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. METHODS: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. RESULTS: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. CONCLUSIONS: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

Alpha-Loop Snaring Technique: Facilitated Snaring Technique for Fully-Deployed and Deformed Coronary Stent Protruding Into the Aorta.

A 59-year-old female was admitted for non-ST-segment elevation myocardial infarction and Killip class 3 heart failure with a left ventricular ejection fraction of 30%. Coronary angiogram showed moderate to severe stenosis over the ostial-proximal left anterior descending artery with minor disease over the left circumflex artery and right coronary artery. We describe a complication encountered where a protruding stent was weakened and elongated during our attempts to remove it, risking possible breakage, stent embolization, and long stent protrusion inside the aorta. We then describe treatment with what we call the alpha-loop snaring technique, which, to our knowledge, is the first report describing this novel approach, which can salvage a failing snaring attempt of a completely deployed and dislodged coronary stent.

Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong.

BACKGROUND: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our center, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure. METHODS: We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications. RESULTS: After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] ml vs. 50 [50-100] ml), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups. CONCLUSIONS: The success rate of hemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Real-time ultrasound-guided bedside closure of arteriotomy wound using MANTA closure device during venoarterial extracorporeal membrane oxygenation decannulation.

Percutaneous closure of arteriotomy wound during peripheral venoarterial extracorporeal membrane oxygenation decannulation was shown to be safe and allow earlier mobilization. The new MantaTM vascular closure device (Essential Medical), designed for the closure of arterotomy wound created by large-bore vascular sheaths up to 25Fr during endovascular catheterization procedures, was reported to be applicable in venoarterial extracorporeal membrane oxygenation decannulation. In this article, we would like to share our experience of using real-time ultrasound guidance to ensure the safe application of Manta during bedside venoarterial extracorporeal membrane oxygenation decannulation.

A Case of Rota-Shock-Pella.

Severe calcified coronary lesions are frequently encountered in today's percutaneous coronary intervention practice and remain a challenging entity in complex and high-risk patients. The present case illustrates the contemporary approach to management of this coronary problem from hemodynamic support, optical coherence tomography assessment, and plaque modification technique. (Level of Difficulty: Advanced.).