Shiva Annamalai

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.

Contrast induced nephropathy after coronary or vascular intervention: More biomarkers than answers

Rising urine NGAL and serum creatinine after 48 hr are potentially useful in predicting persistent creatinine increase in patients with contrast‐induced AKI. Urinary NGAL may allow for early identification of a high‐risk cohort following PCI. Future studies are needed to determine whether renal biomarkers are affected by clinical variables, such as heart failure acute mechanical circulatory support (AMCS) and whether they can be used to identify patients who would benefit from either AMCS reno‐protection during PCI remains unknown.

TCT-196 From Door to Balloon to Door to Unload: A Transcriptomic Analysis Identifies that Primary Unloading Globally Shifts Gene Expression and Preserves Mitochondrial Integrity within the Infarct Zone during the Acute Phase of AMI

We recently reported that compared to Primary Reperfusion (PR), first reducing myocardial oxygen demand by activating an acute mechanical circulatory support (AMCS) pump while delaying coronary reperfusion (Primary Unloading; PU) reduces myocardial damage in models of acute myocardial infarction (

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

TCT-126 Simultaneous, not Staged, Deployment of Biventricular Micro-Axial Flow Impella Catheters (BiPella) is Associated with Improved Survival for Cardiogenic Shock Involving Biventricular Failure

Cardiogenic shock involving biventricular failure (BiVF) is associated with increased in-hospital mortality. This study explored the clinical utility of employing two micro-axial flow Impella catheters for biventricular support (BiPella) in the setting of BiVF. We retrospectively reviewed data from

VASOACTIVE AGENT USE PRIOR TO ACUTE MECHANICAL CIRCULATORY SUPPORT FOR CARDIOGENIC SHOCK IS ASSOCIATED WITH END ORGAN DYSFUNCTION AND MORTALITY

Prior to initiating acute mechanical circulatory support (AMCS) for cardiogenic shock (CS), vasoactive agents are used for hemodynamic support to avert multi-system dysfunction or hemo-metabolic shock. We explored the relationship between vasoactive agents and clinical outcomes in CS. We

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.

The Impella Micro-Axial Flow Catheter is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis from the Global cVAD Registry

BACKGROUND Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock. METHODS AND RESULTS We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy (n = 11) or by clinical history without angiographic evidence of coronary disease (n = 23). A total of 34 patients received an Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42 ± 17 years, left ventricular ejection fraction (LVEF) 18% ± 10%, cardiac index 1.82 ± 0.46 L·min-1·m-2, pulmonary capillary wedge pressure 25 ± 7 mm Hg, and lactate 27 ± 31 mg/dL. Before Impella placement, 32% (n = 11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91 ± 74 hours; 21 of 34 patients (62%) survived the index hospitalization and were discharged with an improved mean LVEF of 37.32% ± 20.31% (P = .001); 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplantation. Ten patients required transition to another mechanical circulatory support device. CONCLUSIONS This is the largest analysis of Impella-supported myocarditis cases to date. The use of Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

TCT-114 Comparing Hemodynamic Profiles and Outcomes in Cardiogenic Shock Requiring VA-ECMO or Impella for Circulatory Support

Use of acute mechanical circulatory support (AMCS) devices for cardiogenic shock (CS) is growing and includes veno-arterial extracorporeal oxygenation (VA-ECMO) or Impella. Few studies have defined hemodynamic profiles nor explored the utility of AMCS in CS. We retrospectively analyzed all patients

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