Nima Aghili

First Successful Use of 2 Axial Flow Catheters for Percutaneous Biventricular Circulatory Support as a Bridge to a Durable Left Ventricular Assist Device

During the past 2 decades, the use of durable mechanical circulatory support (MCS) for advanced heart failure has grown exponentially, in large part, because of clinical trials demonstrating improved rates of survival when compared with medical therapy alone.1 Among patients referred for durable MCS implantation, 2 major predictors of poor survival include (1) clinical instability identified as Interagency for Mechanically Assisted Circulatory Support profiles 1 or 2 and (2) preoperative right ventricular failure.2,3 Right ventricular failure also currently prohibits the use of durable MCS as a destination therapy option. In parallel to growth in durable MCS implants, nondurable or percutaneous MCS device use has also increased since 2007.4 No reports have described the use of percutaneously delivered axial flow catheters to fully support both right and left ventricular (LV) functions before durable MCS implantation. We describe a case illustrating the potential use of axial flow catheters to support a patient with cardiogenic shock caused by biventricular failure (BiVF). A 45-year-old man with stage D ischemic cardiomyopathy and a LV ejection fraction of 10%, moderate RV dysfunction, and moderate tricuspid regurgitation presents with 1 month …

Biventricular Circulatory Support Using 2 Axial Flow Catheters for Cardiogenic Shock Without the Need for Surgical Vascular Access

Biventricular failure in cardiogenic shock remains a major clinical problem. Use of percutaneously delivered, acute circulatory support devices for cardiogenic shock has grown exponentially due in large part to increasing global familiarity and clinical experience demonstrating hemodynamic efficacy of these devices.1 Until recently, percutaneous support options for biventricular failure have been limited to venoarterial extracorporeal membrane oxygenation or biventricular centrifugal flow pumps. We recently reported the first use of biventricular axial flow catheters with the Impella 5.0 and RP (Abiomed Inc) systems, which required surgical vascular access for the 5.0 implant.2 We now report the first patient with cardiogenic shock receiving biventricular support using the Impella CP and RP catheters (BiPella) without the need for surgical vascular access. A 30-year-old woman presented with hypotension and dyspnea after 1 week of a fever and lethargy. Within 24 hours of admission, hemodynamics demonstrated biventricular failure and an echocardiogram showed a left ventricular ejection fraction of 10% and severely dilated right ventricle (RV), despite treatment with an intra-aortic balloon pump, dobutamine, and norepinephrine (Table; Movie I in the …

Use of a percutaneous temporary circulatory support device as a bridge to decision during acute decompensation of advanced heart failure

BACKGROUND Prognosis is poor for patients with decompensated advanced heart failure (HF) refractory to medical therapy. Evaluating candidacy for durable mechanical circulatory support (MCS), cardiac transplantation, or palliative care is complex, and time is often needed to stabilize the patient hemodynamically. The Impella 5.0 (Abiomed, Danvers, MA) is a minimally invasive axial-flow catheter capable of providing full temporary hemodynamic support. We report a multicenter series on the use of this device for bridge to decision (BTD) in decompensated advanced HF patients. METHODS In a retrospective evaluation at 3 centers of patients with advanced HF who acutely decompensated and received the Impella 5.0 for BTD, we analyzed demographics, procedural characteristics, in-hospital and intermediate-term outcomes, and in-hospital complications. RESULTS There were 58 patients who met inclusion criteria from 2010 to 2015. All were inotrope dependent. The mean ejection fraction was 13%, and median age was 59 years (interquartile range, 48-64 years). Mean duration of support was 7 days (range, 0-22 days). Thirty-nine patients survived to next therapy (67%), with most receiving durable MCS (n = 20) or heart transplantation (n = 15). In-hospital complications included bleeding (n = 9) and hemolysis (n = 4). Of patients who survived to the next therapy, 1-year survival was 65% for those who received durable MCS, 87% for those who received a transplant, and 75% for those who were stabilized and weaned. CONCLUSIONS The Impella 5.0 may provide a BTD strategy for patients with advanced HF and acute hemodynamic instability. Prospective studies are needed to evaluate the safety and effectiveness of this device in this patient population.

TCT-135 Increased circulating plasma-free hemoglobin levels, not lactate dehydrogenase, levels identify hemolysis among patients with cardiogenic shock treated with an Impella micro-axial flow catheter

Hemolysis is a complication of micro-axial impeller pumps (Impella). Markers of hemolysis among LVADs include lactate dehydrogenase (LDH) >2.5 times the upper limit of normal (ULN) and plasma-free hemoglobin (pf-Hb) >20mg/dL. We studied the predictive value of LDH or pf-Hb as hemolytic markers in

Increased Plasma‐Free Hemoglobin Levels Identify Hemolysis in Patients With Cardiogenic Shock and a Trans valvular Micro‐Axial Flow Pump

Hemolysis is a potential limitation of percutaneously delivered left-sided mechanical circulatory support pumps, including trans valvular micro-axial flow pumps (TVP). Hemolytic biomarkers among durable left ventricular assist devices include lactate dehydrogenase (LDH) >2.5 times the upper limit of normal (ULN) and plasma-free hemoglobin (pf-Hb) >20 mg/dL. We examined the predictive value of these markers among patients with cardiogenic shock (CS) receiving a TVP. We retrospectively studied records of 116 consecutive patients receiving an Impella TVP at our institution between 2012 and 2017 for CS. Twenty-three met inclusion/exclusion criteria, and had sufficient pf-Hb data for analysis. Area under receiver-operator characteristic (ROC) curve for diagnosing hemolysis were calculated. Mean age was 62 ± 14 years and ejection fraction was 15 ± 5%. Mean duration of support was 5.4 ± 3.5 days. Pre-device LDH levels were >2.5x ULN in 71% (n = 5/7) of 5.0 and 29% of CP patients, while pre-device pf-Hb levels were >20 mg/dL in 14% (n = 1/7) of 5.0 and 25% (n = 4/16) of CP patients. Given elevated baseline LDH and pf-Hb levels, we defined hemolysis as a pf-Hb level >40 mg/dL within 72 h post-implant plus clinical evidence of device-related hemolysis. We identified that 30% (n = 7/23) had device-related hemolysis. Using ROC curve-derived cut-points, an increase in delta pf-Hb by >27mg/dL, not delta LDH, within 24 h after TVP implant (delta pf-Hb: C-statistic = 0.79, sensitivity: 57%, specificity: 93%, p <0.05) was highly predictive of hemolysis. In conclusion, we identified a change in pf-Hb, not LDH, levels is highly sensitive and specific for hemolysis in patients treated with a TVP for CS.

TCT-122 Use of the Impella 5.0 circulatory support device for bridge to decision during acute decompensation of advanced heart failure.

TCT-121 Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: Insights from the cVAD Registry Mir Basir, Akshay Khandelwal, Simon Dixon, Jeffrey Moses, Brijeshwar Maini, Cindy Grines, Theodore Schreiber, E. Magnus Ohman, William O’Neill Henry Ford Hospital, Canton, Michigan, United States; Henry Ford Hospital, Northville, Michigan, United States; Beaumont Hospital, Royal Oak, Michigan, United States; NewYork-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States; Tenet Florida, Delray Beach, Florida, United States; DMC Heart Hospital, Detroit, Michigan, United States; DMC, Warren, Michigan, United States; Duke University Medical Center, Durham, North Carolina, United States; Henry Ford Hospital, Detroit, Michigan, United States

Rotational atherectomy: A persistently relevant niche device.

Rotational atherectomy is effective and safe in selected complex calcified lesions. Despite an older population with more comorbidities, rotational atherectomy is not associated with worse clinical outcomes. Coronary interventionalists need to be well‐trained in both the use of atherectomy techniques as well as how to manage potential complications.