La place de lassistance mcanique Guillaume SCHURTZ Urgences et - - PowerPoint PPT Presentation

La place de l’assistance mécanique

Le support hémodynamique d’une angioplastie à haut-risque: que choisir?

Guillaume SCHURTZ Urgences et Soins Intensifs de Cardiologie Institut Cœur Poumon, CHRU Lille guillaume.schurtz@chru-lille.fr

DÉCLARATION DE LIENS D'INTÉRÊT AVEC LA PRÉSENTATION

Speaker's name : Guillaume SCHURTZ, Lille ABIOMED

Hemodynamic compromise Patient comorbidities Complex CAD Depressed LV function Electrical instability Cardiogenic shock LVEDP PH … Age Comorbidities PAD ACS presentation Prior surgery …

All components associated with increased mortality

HR-PCI definition remains elusive…

LM Last potent vessel MVD Calcification Previous CABG SYNTAX …

• Flow
• Cannula size
• Insertion
• Unloading

Each device has its own features and limitations…

• Coronary perfusion
• Anticoagulation
• Adverse effects
• Costs…

HR-PCI Cardiogenic shock

Mechanical support: one size does not fit all

CA

MCS

Dysrhythmias Technical difficulties AKI No-reflow Reperfusion injury Cardiac arrest Cardiogenic shock Stunning

What could happen to you during HR-PCI…

Primary Objectives Appropriate device selection

1. Reducing LV work and MvO2 2. Ensuring end-organ and myocardial perfusion 3. Anticipation!!!!

Perera, D. et al. Elective IABP during high-risk PCI. JAMA (2010) Perera, D. et al. Long-term mortality data from the BCIS-1 study. Circulation (2013) Patel, RM. et al. IABC and infarct size in patients with acute anterior MI without shock. JAMA (2011)

N = 301 HR PCI LVEF≤30% BCIS score>8 12% cross-over

BCIS-1 study

Is IABP a good candidate?

CRISP-AMI study

N = 337 Anterior STEMI w/o shock EF=47% 8% cross-over

Exhausted autoregulation and persistent ischemia is required for IABP efficacy

Better patient selection?

IABP: Game Over?

CRISP-AMI substudy

ST≥15mm ST-R<50%

SEMPER FI trial = negative (n = 100)

Schampaert, S. et al. IABP support in the isolated beating porcine heart in non ischemic and ischemic heart failure. Artif Organs (2015) Van Nunen, LX. et al. IABP reduces mortality in a large anterior MI complicated by persistent ischemia. EuroIntervention (2015)

Mechanical Work

O2 Demand

Coronary Flow Microvascular Resistance

O2 Supply

Wall Tension Inflow (Ventricle) Outflow (aortic root) Aortic valve

EDV, EDP

LV unloading

Cardiac Output

Hemodynamic Protection

Flow AOP

Impella: a cardio-circulatory support

• 1. Decline in IABP use
• 2. Increase of others MCS
• 3. MCS patients are the sickest one
• 4. MCS use is clustered at a small number of hospitals

Use of pVADs during PCI + CS in the US

Khera, R. et al. Trends in the use of pVADs. JAMA Intern Med (2015) Sandhu, A. et al. Use of MCS in patients undergoing PCI. Circulation (2015)

No MCS IABP Other MCS

pVAD IABP

Does it translate into a clinical benefit?

pVADs improves hemodynamics, but…

O’Neil, WW. et al. A prospective, randomized trial of hemodynamic support with Impella 2.5 vs IABP in HR-PCI. Circulation (2010) Amin, AP. et al. The evolving landscape of Impella use in the US among patients undergoing PCI with MCS. Circulation (2019) Dhruva, SS. Utilization and outcomes of Impella vs IABP among patients with AMI complicated by cardiogenic shock undergoing PCI. AHA (2019)

PROTECT II Trial

N= 448 Impella 2.5 vs IABP ULM or 3VD and LVEF<30% Non-emergent PCI

Never forget, MCS could be harmful

(but observational studies…)

MACCE with a more relevant MI definition Impella support permitted a more complete revascularization

Potential link with MACCE

However, pVADs are not dead!!

Dangas, GD. et al. Impact of hemodynamic support with Impella 2.5 vs IABP on prognostically important clinical outcomes in patients undergoing HR PCI. Am J Cardiol (2014) Kovacic, JC. et al. Patients with 3VCAD and impaired LV function undergoing PCI with Impella 2.5 have improved 90-day outcomes. J Interv Cardiol (2015) Burke,DA. et al. The value of left ventricular support in patients with reduced LVEF undergoing extensive revascularization. JACC Interv (2019)

However, pVADs are not dead!!

Similar outcomes despite higher-risk patients in the pVAD group N=139 (24) HR-PCI w/o shock or STEMI N=198 (69) pVAD improves outcomes

Shamekhi, J. et al. Impact of hemodynamic support in patients undergoing HR-PCI. Am J Cardiol (2019) Henriques, JPS. et al. Evaluating the lurining curve in the PROTECT II trial. Am Heart J (2014) Ameloot, K. et al. New-generation MCS during HR-PCI. EuroIntervention (2019)

• 1. A learning effect could have influenced PROTECT II results
• 2. Are powerful devices more efficient?

Why not VA-ECMO?

• 4-5L of actual flow
• Independent of heart function
• More severe CS or CA
• Biventricular / respiratory failure

Increases wall stress

• Loads the heart
• Can be modulated (TPR, contractility)
• Is a circulatory support

Exact prevalence and incidence of complications is ascertain, but remains high

Lack of RCT for HR-PCI+++

You must avoid vascular complications!

Major impact of bleeding +++

• Mortality
• Length of stay
• Health care costs

Redfors, B. et al. Mortality, length of stay, and cost implications of procedural bleeding after percutaneous interventions using large-bore catheters. JAMA Cardiol (2017)

Experience, US guidance and closure devices can help you…

Conclusion: take home messages

• 1. Patient selection is of paramount importance for HR-PCI

Consensual definition

• 2. Which patient would benefit mosts?

Careful evaluation before device selection

• 3. Don’t forget « after PCI »

Look beyond coronary arteries… !

• 4. Minimizing complications

Perform HR PCI with experienced operators

Fascination of devices may dampen your thinking…

Merci de votre attention