HEMODYNAMIC SUPPORT FOR HIGH RISK PCI AND CARDIOGENIC SHOCK: FINDING THE SWEET SPOT
George W. Vetrovec, M.D.,
VCU Pauler Heart Center, Virginia Commonwealth University, VA, USA
Hemodynamic support (HD) requires decision-making related to device, timing of use, and appropriateness of use. Appropriate use is critical. Adopting a “wait and watch” or "getting by" philosophy potentially leads to less optimal results. The real risk of "getting by” reduces late outcomes despite acceptable immediate results.
In Cardiogenic shock, device choice is based on effectively increasing cardiac output (CO) as well as limiting ischemia by reducing preload. IABP and Impella devices both increase blood pressure but Impella more effectively increases CO while decreasing preload. Earlier support, before reperfusion and/or high dose inotropes yields excellent late results. Impella 2.5 in AMI/CS in the USPella Registry demonstrated that Impella 2.5 was associated with improved survival: pre PCI Impella group had a hospital survival of 65.1% compared to 40.7% survival for later support. (p=0.003).
In High-risk PCI (HRPCI) appropriate HD requires low LVEF, and/or severe, complex coronary anatomy and/or general patient risk. Device choice again favors Impella for its ability to provide CO during sudden loss of LV contractility. Importantly, getting out of the lab is feasible without support in many cases but late outcome is enhanced by better initial lesion results. The PROTECT II Trial randomly compared pre-procedure IABP vs. Impella 2.5 support for patients requiring prophylactic hemodynamic support during non-emergent, HRPCI. Impella support had more extensive rotational atherectomy use, greater revascularization but shorter support times post procedure with numerically lower MACCE at 30 days (p=NS) but significantly lower 90 day MACCE rates (p<0.023) and less repeat hospitalizations over 90 days compared to the IABP arm supporting the importance of an better initial result leading to better late results.
In conclusion, HD decisions are important. Hitting the "sweat spot" is critical to limit risk while achieving optimal acute and late results. Early and effective support supports improved outcomes.