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Indications for Hemodynamic Support in the Cath Lab
Debate surrounds appropriate use of hemodynamic support.
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As physicians increasingly treat patients with more complex CAD, the use of hemodynamic support in the cath lab may become commonplace.
However, the availability of multiple systems, including the intra-aortic balloon pump (IABP), Impella heart pumps (Abiomed), TandemHeart pumps (TandemLife) and extracorporeal membrane oxygenation, raises questions about which device is appropriate for which patient.
Six experts — Navin K. Kapur, MD; Hari R. Mallidi, MD, FRCSC; William W. O’Neill, MD; E. Magnus Ohman, MD; Steve K. Singh, MD, MSc, FRCSC; and Paul S. Teirstein, MD — shared their experiences with Cardiology Today’s Intervention.
How and when are you using hemodynamic support in the cath lab?
Navin K. Kapur, MD
In our cath lab, we use IABP, Impella pumps, veno-arterial ECMO (VA-ECMO) and occasionally TandemHeart devices. Our primary indications for use of hemodynamic support include high-risk, complex interventional procedures and cardiogenic shock. We also utilize these devices in patients with advanced heart failure who may be being evaluated for other procedures, such as heart transplant or implantation of a left ventricular assist device.
At my institution, we determine which hemodynamic support platform is appropriate based on the patient’s clinical and hemodynamic condition. In complex interventional procedures, we generally use the Impella platform for left-sided support. For patients with advanced HF or cardiogenic shock, we first perform a hemodynamic evaluation with a pulmonary artery catheter, then use left-sided or right-sided Impella pumps based on which side of the heart is involved. If both sides are involved, we use Impella pumps for both or VA-ECMO. Since VA-ECMO increases the workload of the left ventricle, we commonly use VA-ECMO in combination with an IABP or Impella device to provide LV unloading. In patients with cardiac arrest or severe problems with oxygenating their bloodstream, we use VA-ECMO to provide oxygenation or lung support while also providing BP support.
Hari R. Mallidi, MD
There are two basic categories of mechanical circulatory support during interventional cardiology procedures that are based on urgency.
The first category involves patients who present with cardiogenic shock and are going to the cath lab primarily for diagnosis and possible intervention. In this situation, hemodynamic support needs to be instituted rapidly in the ED or the cath lab. We would offer ECMO or other forms of temporary support, such as Impella or TandemHeart, to allow completion of the diagnostic procedure and possible intervention. Generally, these patients leave the cath lab on support to wait for myocardial recovery.
The second category includes stable patients undergoing planned interventions, such as transcatheter aortic valve replacement, where there is a high risk for brief periods of hemodynamic compromise. These patients can usually be weaned off support after the procedure.
For those patients who require temporary support during completion of a procedure, we usually use ECMO vs. Impella or TandemHeart because it provides full support to the patient and allows the physician to concentrate on the procedure.
William W. O’Neill, MD
In my experience, there are two philosophies. A physician can choose to proceed with a case without hemodynamic support and then use a device if they experience problems. However, when complications occur, the physician must deal with a patient who has hemodynamic collapse or CPR. It is far more dangerous to resuscitate that patient and use a support device than to treat those patients prophylactically.
In our cath lab, we primarily use Impella and TandemHeart for hemodynamic support. The two main indications for use are acute MI cardiogenic shock and protected PCI.
For acute MI shock, we are achieving an 80% survival with rapid initiation of Impella followed by angioplasty and aggressive down-titration of inotropes. This strategy has become routine for our patients with acute MI shock and our success leads us to believe this will become standard of care.
For protected angioplasty, patients have severe ischemic coronary disease but also poor ventricular function. The protection for those patients is extremely important to stabilizing them and preventing ischemic or hypotensive complications during procedures.
E. Magnus Ohman, MD
We use several hemodynamic support devices, including IABP, Impella and ECMO, in a variety of clinical settings.
First, as a transplant center, many of our patients are awaiting cardiac transplantation for a long period of time. Among those, we use IABP due to need for cardiac support that may be several weeks in duration.
Second, we use hemodynamic support devices for elective, high-risk PCI, predominantly in patients with impaired ejection fraction and significant multivessel disease or unprotected left main PCI. We tend to use Impella 2.5 or Impella CP, depending on the patient’s size. Rarely, we use IABP if a patient has severe aortic valve disease or severe peripheral vascular disease where the Impella cannot be placed.
Third, we utilize support devices in patients with severe cardiogenic shock. We primarily use Impella because it offers the best support with ease of use and allows us to place the patient on support quickly.
Fourth, we use Impella 2.5 among patients with long-term VA-ECMO to help empty the left ventricle; this also helps wean patient with severe hemodynamic compromise off the ECMO.
Finally, in the patients with cardiac arrest and ongoing CPR, we tend to use VA-ECMO to reestablish the circulation.
Steve K. Singh, MD, MSc, FRCSC
Each system has differences in their specifications/characteristics: flow rates, anatomical requirements for cannulation and ability to allow ambulation, as examples. Therefore, patients’ clinical presentation can direct a physician “shock team” toward which device may be most appropriate.
In my role as surgical director of heart transplantation and mechanical circulatory support, I work with the cath lab in two settings: chronic end-stage HF and acute cardiogenic shock.
In patients with HF who are moving toward having a transplant, temporary hemodynamic support as a bridge to transplant is planned. We can more carefully consider which device to use based on their aforementioned characteristics. We will electively place hemodynamic support to bridge these patients to a permanent device or transplant, usually using an axillary Impella 5.0, TandemHeart or, in rare situations, ECMO.
In the acute setting of undifferentiated cardiogenic shock, we usually place patients on ECMO because it offers complete lung and heart support, as well as left- and right-sided heart support.
Paul S. Teirstein, MD
For cardiogenic shock, we frequently use Impella and occasionally ECMO when a patient is in crisis. For elective PCI, the indications are more variable.
Personally, I confine most of my use of hemodynamic support to patients with both high-risk clinical features and complex anatomy. If a patient with impaired LV function is having a stent placed in a vessel that is the only remaining circulation or an unprotected left main coronary artery, I consider BP and anatomy. If the patient has adequate BP and simple anatomy, I will not use support. I would instead use the radial approach and avoid the large-bore femoral access needed for cardiac support. This minimizes the risk of access-site complications and gets the patient in and out of the hospital quickly.
However, the decision to use support depends on how comfortable a physician is with the patient’s anatomy. Some physicians may have less experience with stenting in more complex disease and therefore may be concerned about performing the procedure quickly and without causing hypotension. In those cases, I encourage them to have a lower threshold for using Impella support. – by Melissa Foster
- For more information:
- Navin K. Kapur, MD, is executive director of the CardioVascular Center for Research and Innovation; director of the Acute Circulatory Support Program; director of the Interventional Research Laboratories; and investigator at the Molecular Cardiology Research Institute at Tufts Medical Center. He be reached at nkapur@tuftsmedicalcenter.org.
- Hari R. Mallidi, MD, is co-director of the Surgical Program in Heart and Lung Transplantation and Mechanical and Circulatory Support; senior surgeon in the Collaborative Center for Advanced Heart Disease; and executive director of the ECMO Program at Brigham and Women’s Hospital. He can be reached at hmallidi@bwh.harvard.edu.
- William W. O’Neill, MD, is the medical director for the Center of Structural Heart Disease at Henry Ford Hospital, and a Cardiology Today’s Intervention Editorial Board Member. He can be reached at woneill1@hfhs.org.
- E. Magnus Ohman, MD, is professor of medicine at the Duke University Medical Center and the Kent and Siri Rawson Director of the Duke Program for Advanced Coronary Disease. He can be reached at ohman001@mc.duke.edu.
- Steve K. Singh, MD, MSc, FRCSC, is the surgical director of Heart Transplantation and Mechanical Circulatory Support at Brigham and Women’s Hospital. He can be reached at ssingh24@bwh.harvard.edu.
- Paul S. Teirstein, MD, is the medical director of Scripps Prebys Cardiovascular Institute. He can be reached at pteirstein@scrippsclinic.com.
Disclosures: Kapur reports he receives institutional research grants from Abbott, Abiomed, Boston Scientific, Maquet and TandemLife; he receives speaker honoraria or consulting fees from Abbott, Abiomed, Boston Scientific and Maquet and he is national principal investigator of the SHIELD II Trial (Abbott) and the Door to Unloading Trial (Abiomed). Teirstein reports he receives honoraria from Abbott, Abiomed and Boston Scientific. Mallidi, O’Neill, Ohman and Singh report no relevant financial disclosures.