Dr. Navin Kapur Discusses Hemodynamic Support for High-Risk PCI Patients at TCT 2015
On Tuesday evening, October 13, Dr. Navin Kapur of Tufts Medical Center, Boston, MA presented “PCI of High-Risk Patients Under Hemodynamic Support: For Whom and With What?” at the evening session on Complex, High-Risk and Indicated PCI, often called CHIP.
Dr. Kapur began by defining risk during PCI as achieving angiographic success, without complication and with benefit to the patient. Since complex coronary artery disease can occur with and without risk, high-risk patients are defined as those with left ventricular ejection fraction of 35%. Other comorbidities add additional risk, especially severe congestive heart failure, peripheral artery disease, and prior surgery. Complete total occlusion adds another level of complexity.
High-risk cases identified CHIP are cases that fall in the area under the curve (AUC) for angina and heart failure. Dr. Kapur noted that high-risk patients with medium or high anatomic risk are most suitable for Protected PCI. He explained that transmyocardial perfusion is dependent on the difference between mean arterial pressure and venous pressure. With hemodynamic support the mean arterial pressure goes up, the venous pressure goes down, and perfusion improves.
Dr. Kapur presented a CHIP case performed with the intra-aortic balloon pump, which did not provide adequate support in this particular case. In contrast, the Impella device maintained mean arterial pressures. Maintaining hemodynamic support is necessary for complete revascularization. Complete revascularization is associated with improved long-term outcomes.
Dr. Kapur provided an analogy of PCI to chess—PCI without hemodynamic support in high-risk patients is like speed chess, and adds a level of complexity on top of the normal stress of the case. He concluded, “it’s better to have the support and be able to play chess than have the added stress of having to play speed chess.”
The Impella 2.5 system is a temporary (<6 hours) ventricular support device indicated for use during high risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, including a cardiac surgeon, has determined high risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 in these patients may prevent hemodynamic instability which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.
Protected PCI and use of the Impella 2.5 is not right for every patient. Patients may not be able to be treated with Impella if they have certain pre-existing conditions, which a cardiologist can determine, such as: severe narrowing of the heart valve, severe peripheral artery disease, clots in blood vessels, or a replacement heart valve or certain heart valve deficiencies. Additionally, use of Impella has been associated with risks, including, but not limited to valvular and vascular injury, bleeding, and limb ischemia in certain patients. Learn more about the Impella devices’ approved indications for use, as well as important safety and risk information at www.protectedpci.com/indications-use-safety-information/