Amir Kaki

Real‐world supported unprotected left main percutaneous coronary intervention with impella device; data from the USpella registry

Patients with left main (LM) coronary artery disease are increasingly being treated with percutaneous revascularization (PCI). The safety, feasibility, and efficacy of unprotected LM intervention (ULMI) with hemodynamic support by Impella device have not been evaluated previously.

Should Ultrasound Guidance Be Routinely Used for Femoral Artery Access

ABSTRACT Ultrasound-guided femoral artery access should always be utilized as it has been shown to significantly reduce vascular complications, number of arterial access attempts, accidental venipunctures, and time to access. Despite the increased adoption of transradial access, the conventional femoral artery cannulation remains the primary route for performing peripheral angiography and cardiac catheterization in the setting of high-risk interventional procedures requiring mechanical hemodynamic support. Similarly, with the expansion of structural heart interventions such as transcatheter aortic valve replacement and mitral valve interventions, femoral access has been increased especially for large-bore sheaths.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

BACKGROUND The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR). METHOD Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility. RESULTS A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group. CONCLUSION In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism

BACKGROUND Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown. METHODS We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP. RESULTS Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge. CONCLUSION In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.

In Reference to Trends, Etiologies, and Predictors of 90-Day Readmission After Percutaneous Ventricular Assist Device Implantation: A National Population-Based Cohort Study

We read with interest Virk et als recent informative study regarding trends, etiologies and predictors of 90-day readmission after percutaneous ventricular assist device (pVAD) implantation. 1 We have a number of comments and concerns regarding this article. This article is protected by copyright. All rights reserved.

Left ventricular perforation after Impella placement

We read with interest Peritz et al.’s recent report of fatal left ventricular perforation occurring after placement of an Impella 2.5 catheter [1]. The device had been implanted at another center and there had been an extended delay in transfer. The authors postulate that, during transportation of the patient, the Impella catheter had migrated deep into the left ventricle and subsequently eroded through the wall. The authors do not, however, provide any information regarding the implantation procedure or postprocedural monitoring at the referring center. Without such information, it is not possible to determine when and how the perforation occurred. Indeed, it is possible that the perforation occurred soon after implantation and that the mechanism of perforation was one other than gradual erosion through the myocardium. In considering such alternative mechanisms, analysis of procedural details is key. At our center, and other centers that we are familiar with, prior to placement of the rather bulky (9 Fr) Impella catheter in the left ventricle, the aortic valve is first crossed with a 6 Fr end-hole catheter, such as a Multipurpose or Judkins right catheter. Next, an 0.1800 deployment wire is advanced through the end-hole catheter which is then changed out for the pigtail shaped Impella catheter [2]. Of these two catheter types, it is the end-hole catheter that historically has been associated with cardiac perforation [3]. Accordingly, a possible alternative explanation for the perforation occurring in the reported patient is that the perforation was actually caused by an end-hole catheter used for initial crossing of the aortic valve. Then as the deployment wire was advanced through this catheter, the wire became embedded in the area of perforation, possibly enlarging it, and, subsequently serving as a rail to the perforation site for the Impella catheter. Alternatively, the deployment wire itself may have initiated the perforation. A clearer understanding of mechanisms responsible for this newly described complication associated with implantation of the Impella device may lead to earlier detection and effective management. Accordingly, we invite the authors of this important report to provide more technical details regarding the initial implantation of the Impella device in their patient.

Successful Treatment of Occlusive Left Main Coronary Artery Dissection by Impella-Supported Stenting

We report successful treatment of a patient, who, during diagnostic angiography, developed an ostial left main coronary artery dissection with stump occlusion of the vessel. First, mechanical circulatory support with an Impella CP device was established. Then, patency of the left coronary system was achieved by placement of stents in the left anterior descending, left circumflex, and left main coronary arteries. On completion of the procedure, left ventricular systolic function, as assessed by echocardiography, was normal. At 24-month clinical follow-up, the patient remains angina-free and well. This is the first reported case of the use of an Impella device to support treatment of iatrogenic left main coronary artery dissection.

Outcomes and Effects of Hepatic Cirrhosis in Patients Who Underwent Transcatheter Aortic Valve Implantation

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without liver cirrhosis are scarce. This study aimed to assess the clinical outcomes and impact of liver cirrhosis on patients who underwent TAVI. Patient with liver cirrhosis who underwent TAVI 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of liver cirrhosis on inpatient mortality. Secondary outcomes were the impact of liver cirrhosis on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The cirrhotic patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.59 to 2.10, p = 0.734) or after procedural complications. Furthermore, cirrhotic patients were less likely to develop vascular complications requiring surgery (OR 0.47, 95% CI 0.23 to 0.98, p = 0.043), to develop after procedural deep vein thrombosis(OR <0.00, 95% CI <0.001 to <0.0001, p <0.0001), and to require pacemaker implantation. However, cirrhotic patients were more likely to undergo nonroutine hospital discharges (OR 1.50, 95% CI 1.15 to 1.96, p = 0.003). In conclusion, TAVI is a safe and reasonable therapeutic option for cirrhotic patients with severe aortic stenosis, requiring aortic valve replacement.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

Background The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)‐guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US‐guided RA access compared with palpation alone on first‐pass success to access RA. Methods and Results Meta‐analysis of 12 randomized controlled trials comparing US‐guided with palpation‐guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound‐guided radial access was associated with increased first‐attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16‐1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32‐0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27‐1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions Ultrasound‐guided technique for RA access has higher first‐attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.