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Percutaneous Ventricular Assist Devices:
High Risk PCI and Shock
Michael J. Lim, MD, FACC, FSCAI
Jack Ford Shelby Endowed Professor
Co-Director, Center for Comprehensive Cardiovascular Care
Saint Louis University
Disclosures
Relevant Financial Relationships over the past 12 months:
Research Support Astellas
Consultant Acist Medical
Speaker St. Jude Medical, Abiomed
Case Scenerio
• 69 yr old man with DM, HTN, and smoker presents complaining of dyspnea on exertion, orthopnea, PND, and chest pressure. Chest pressure episodes lasting up to 20 minutes.
• ROS + for claudication symptoms
• Workup – EF 20%. Troponin peak at 1.0
Summary
• 3 Vessel CAD
• Terrible LV function
• Diabetic CABG
SYNTAX Score: 43.5 Surgeon’s view: STS • Mortality 4.7% • Morbidity or Mortality 41.6%
NO
Percutaneous Ventricular Support
CO
MAP
PCWP
Hemodynamic Effects
• Trans-septal cannula into left atrium
• 15–17 F arterial cannula
• Nonpulsatile pump (~4 L/min)
TandemHeart Impella • 13 F arterial cannula
• Non-pulsatile
• 2.5 and CP catheters for purcutaneous use
IMPELLA 2.5 + PCI
IABP + PCI
Primary Endpoint = 30-day Composite MAE* rate
1:1 R
Patients Requiring Prophylactic Hemodynamic Support During Non-Emergent High Risk PCI on
Unprotected LM/Last Patent Conduit and LVEF≤35% OR 3 Vessel Disease and LVEF≤30%
Follow-up of the Composite MAE* rate at 90 days *Major Adverse Events (MAE) : Death, MI (>3xULN CK-MB or Troponin) , Stroke/TIA, Repeat Revasc, Cardiac or Vascular Operation or Vasc. Operation for limb ischemia, Acute Renal Dysfunction, Increase in Aortic insufficiency, Severe Hypotension, CPR/VT, Angio Failure
PROTECT II - Design
Circulation 2012; 126:1717-27
Patient Characteristics IABP (N=211)
Impella (N=216)
p-value
Age 67±11 68±11 0.583
Gender-Male 82.0% 80.6% 0.704
History of CHF 82.9% 91.2% 0.011
Current NYHA (Class III / IV) 54.9% 58.5% 0.485
Diabetes Mellitus 49.3% 53.2% 0.414
Renal insufficiency 30% 22.7% 0.086
Peripheral Vascular Disease 27.0% 25.4% 0.697
Implantable Cardiac Defib. 31% 35.6% 0.304
Prior CABG 28.9% 39.4% 0.023
LVEF 24.0±6.3 23.3±6.3 0.258
STS Mortality score 6±7 6±6 0.562
Not Surgical Candidate 64.5% 63.4% 0.825
SYNTAX score 29.5±13.7 30.3±13.2 0.595
Circulation 2012; 126:1717-27
Procedural
Characteristics IABP (N=211)
Impella (N=216)
p-
value
Use of Heparin 82.4% 93.5% <0.001
IIb/IIIa Inhibitors 26.5% 13.4% <0.001
Total Contrast Media (cc) 241±115 267±141 0.035
Rotational Atherectomy (RA) 9.0% 14.2% 0.083
Median # of RA Passes/lesion (IQ
range) 1 (1-2) 3 (2-5) 0.001
Median # of RA passes/pt (IQ range) 2.0 (2.0-4.0) 5.0 (3.5-8.5) 0.003
Median RA time/lesion (IQ range sec) 40 (20-47) 60 (40-97) 0.004
RA of Left Main Artery 3.1% 8.0% 0.024
Total Support Time (hours) 8.23±21.0 1.86±2.7 <0.001
Discharge from Cath Lab on device 37.7% 5.6% <0.001
Circulation 2012; 126:1717-27
PROTECT II MAE Outcome
IABP
IMPELLA
MAE= Major Adverse Event Rate
Intent to Treat (N=448)
p=0.294
N=225
p=0.066
N=224
p=0.092
N=216
↓ 22% MAE
p=0.023
N=215
Per Protocol (N=427)
Per Protocol= Patients that met all incl./ excl. criteria.
N=223 N=229 N=211 N=210
Circulation 2012; 126:1717-27
PROTECT II MAE Timing Per Protocol Population, N=427
Log rank test, p=0.048
IABP
IMPELLA
Composite Major Adverse Event (MAE)
LVEF Improvement Post PCI
p<0.001
Baseline 90 days
LVEF (%) N=303 patients with LVEF measurements available at baseline and 90 days
22%
NYHA Improvement Post PCI p<0.001
Baseline 90 days
NYHA Class Distribution
N=223 patients with NYHA measurements available at baseline and 90 days
Class I
Class II
Class III
Class IV 58% reduction
in Class III,IV
Case Scenerio #2
• 73 yr old man s/p CABG in 1996 and subsequent DES to his LCX in 2005 presents complaining of significant chest discomfort worsening over the last 6 months
• Over the past 2 weeks, he gets it at rest and it wakes him from sleep
Case Scenerio #2
• Angina relieved – walks all around the hospital all night. Discharged home…
• Decides that he only needs to take his aspirin, and not his second anti-platelet agent. 1 week after stents placed, presents to local ER with severe substernal chest pain. BP drops into the 80’s. Started vasopressors. 1 episode of Vtach requiring cardioversion. Emergent transfer
Hemodynamics
Initial Pressure – On Levophed
Hemodynamics
LV Pressure – 80/25
Insertion of Impella CP
Final Aortic Pressure – Levophed OFF
Cardiogenic Shock: In-Hospital Mortality
0
10
20
30
40
50
60
70
80
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Total <75 y ≥ 75 y
Babaev et al, JAMA 2005; 294:448
60.3
47.9
IABP Shock II Trial Design
OMM n=301 IABP n=299
Primary Efficacy Endpoint = 30-day all-cause mortality rate
1:1
R
Patients Presenting with AMI complicated by cardiogenic shock are randomized to IABP or to Optimal Medical Management. Mechanical
complications or resuscitation >30 min were excluded. All patients were to be revascularized by PCI or CABG
Safety measures include major bleeding, peripheral ischemic complications, sepsis, and stroke
Lancet 2013; 382:1638-45
No Difference in Outcomes
Lancet 2013; 382:1638-45
USPella Registry
• Retrospective observational multicenter study documenting use of hemodynamic support in patients with acute myocardial infarction / cardiogenic shock undergoing percutaneous revascularization
• 119 patients with Impella 2.5 at 32 centers in US and Canada
J Intervent Cardiol 2014; 27:1-11
Presentation Characteristics at Admission
All
(N=119)
STEMI
(N=86)
NSTEMI
(N=33) p-value
Transferred from outlying hospital 53% (112) 48% (79) 64% (33) 0.133
Preadmission Cardiogenic shock 59% (111) 69% (80) 32% (31) 0.0005
Preadmission Cardiac Arrest 20% (100) 27% (73) 0% (27) 0.002
Transfer Admission on IABP 15% (111) 20% (81) 3% (30) 0.037
Door to Impella time for patients
admitted with CS (Median, min.) 227 185 1283 <0.0001
Patient Characteristics Prior to Impella Support Initiation
54%
17%
0%
20%
40%
60%
80%
53%
58%
77%
46%
84%
Improvement of Hemodynamic and Metabolic Parameters with Impella
Cardiac Index
Car
dia
c In
dex
(l
/min
/m2)
Wedge Pressure
0
1.6
1.8
2.0
2.2
2.4
2.6
On Impella
PC
WP
(m
mH
g)
0
20
24
28
22
26
30
Pre Impella*
1.9±0.7
pH
pH
Level
0
7.1
7.2
7.3
7.4
7.5
7.0
7.2±0.2
On Impella
Pre Impella
On Impella
Pre Impella
2.8±0.7
32±12
20±11
p=0.0001
P<0.0001 p<0.0001
Mean Arterial Pressure
61±18
94±23 p<0.0001
7.4±0.1
MA
P
(mm
Hg
)
0
50
60
70
80
90
On Impella
Pre Impella*
100
Outcome: Survival to Discharge Post PCI
Pre-PCI
64.6%
Post-PCI
39.4%
Timing of Support Initiation
Impella Support Initiation
Survival to Discharge For ALL Patients
p=0.007
N=48 N=71
Post-PCI
60.0%
Pre-PCI
37.7%
Impella Support Initiation
STEMI
N=25 N=61
Post-PCI
69.6%
Pre-PCI
50.0%
Impella Support Initiation
NSTEMI
N=23 N=10
Summary
• Percutaneous ventricular support possible through a single arterial access
• High-Risk PCI
• Allows more-complete revascularization
• Translates into improved long-term outcomes
• Cardiogenic Shock
• No benefit for balloon pump therapy
• No prospective randomized trials
• Observational data supporting use