Impella Buys Time for Complex Procedures: ACC.2016 Live Case
A live case transmission presented at the American College of Cardiology 2016 Scientific Session on April 3 turned into a lesson on patience, as well as the necessity for hemodynamic support.
Broadcasting from Barnes-Jewish Hospital in St. Louis, John M. Lasala, MD, and Jasvindar Singh, MD, tackled the case of an 84-year-old man with severe multivessel disease featuring a 90% calcified mid RCA and 80% tandem calcified proximal and mid LAD stenoses.
With an ejection fraction at 20 percent and blood pressures of 90-100, the patient would need assistance during the atherectomy procedure. “I think the complication of those events really mandate hemodynamic support,” said Dr. Lasala.
The panel of experts observing from Chicago agreed. “This does deserve support to really perform this complex PCI in a relaxed fashion and even if something goes wrong, you know that you will have a safety net,” said Giora Weisz, MD, of Shaare Zedek Medical Center, Jerusalem.
Dr. Lasala explained that they were using the Impella 2.5™ heart pump for support, and that they also placed a Swan-Ganz catheter. Ricardo A. Costa, MD, of the Dante Pazzanese Institute of Cardiology in São Paulo, Brazil, noted that while he doesn’t routinely use support for complex interventions, this was a case where it was warranted.
Halfway through the procedure, the need for hemodynamic support was underscored during a lengthy application of rotational atherectomy. It took seven or eight passes before the burr passed through the calcified lesion. “People who are doing rotational atherectomy with the Impella in place clearly can go for a much longer time, and do a more thorough job,” said Dr. Lasala.
“With this kind of complex case, you need patience,” added Dr. Singh, and without hemodynamic support, there’s less room for patience. “Imagine trying to heal this lesion with a balloon.”
Panelists echoed the need for patience, urging the operators not to settle for “just OK” stent expansion, even going back with a bigger burr if necessary. “You don’t want the patient coming back to the lab,” said Sunil Rao, MD, of Duke Clinical Research Institute.
Persistence paid off, and while it took extra effort, the case was handled without major complication.
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/.