PERICUTANEOUS HEMODYNAMIC SUPPORT FOR HIGH RISK PCI: INDICATIONS AND RESULTS
George W. Vetrovec, M.D., VCU Medical Center Richmond, VA, USA
Hemodynamic support has a limited but very specific and important role in the management of myocardial ischemia in the cardiac catheterization lab. Indications for its use include (1) cardiogenic shock, particularly in the setting of Acute Myocardial Infarction in which case the immediate support provides the time and hemodynamic stability to complete revascularization. Until recently, operators have relied heavily on the intra aortic balloon for hemodynamic support, but recent studies have raised questions regarding the effectiveness of the IABP in such cases thus further supporting this option. In addition, hemodynamic support is useful as an adjunct to (2) high anatomic risk PCI to provide “hemodynamic safety” and again, time to allow complete and high quality PCI. High anatomic risk is generally defined as LVEF of < 30% or 3 vessel disease and an LVEF of < 35%. The latter use has developed as the application of percutaneous revascularization for the treatment of severe, multi-vessel coronary artery disease has become more common, particularly in patients who are surgical “turndowns” because of multi-organ risk factors adversely impacting more usual surgical intervention.
Most commonly, hemodynamic support is provided by percutaneous insertion of an Impella catheter (Abiomed, Danvers, Ma.) with a potential cardiac output of up to 3.9 L/min using the newest catheter design. Data suggests better outcomes for patients treated early, before cardiogenic shock occurs or escalates. Defining patient populations most likely to benefit from percutaneous hemodynamic support in the absence of cardiogenic shock continues to evolve.
By case examples the above patient types will be illustrated emphasizing the value of hemodynamic support with data from pertinent studies documenting the benefit.
In summary, hemodynamic support for patients cardiogenic shock as early as possible as well as in conjunction with specific, risk PCI can improve outcomes.