hemodynamic support in pci
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Hemodynamic Support in PCI
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Physiology Myocardial Oxygen Supply and Demanda,b
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Goals of Hemodynamic Support During High-Risk PCI
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Types of Hemodynamic Support in the Cath Lab
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Hemodynamic Support Devices for the Cath Lab
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Indications for Cath Lab Hemodynamic Support
Cath Lab hemodynamic support
Elective high-risk PCI
PCI in Cardiogenic shock
• Impaired LV function• PCI to a single last patent
conduit • PCI of vessel(s) supplying a
large myocardial territory Recent high-risk ACS
• Heterogeneous • Non-atherosclerotic CAD• Underlying LV impairment,
scar, valvular disease or dysrhythmia
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Percutaneous Cardiac Assist Devices (cont)
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Pressure vs Flow DevicesMechanisms
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Assist TreatmentsEffect on Myocardial Oxygen Demand
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Complementary Mechanisms
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Patient SelectionIABPa
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IABP Randomized TrialsCRISP AMI
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IABP Randomized TrialsCRISP AMI Substudy
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IABP Randomized TrialsBCIS-1
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Patient Selection IABP (cont)
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IABP in MISHOCK and SHOCK II Trials
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AFPPatients with ST-Segment Elevation AMI and/or Cardiogenic Shocka
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Individualizing Cardiac Support Therapy
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Individualizing Cardiac Support Therapy (cont)
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IABP vs AFP vs CFPTypical Practice Scenarios
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Conclusions
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Evidence for IMPELLA system
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PROTECT II Trial Design
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Procedural Characteristics
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LVEF and NYHA Improvement Post PCI
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PROTECT II: Per Protocol MAE (N=427)
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PROTECT II MAE Outcome Pre-specified High Risk PCI Without Atherectomy Group Per Protocol (N=374)
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USPELLA Registry: Impella® Insertion Timing (N= 154)
O’Neill et al, J Interven Cardiol 2013;9999:1-11
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Outcome: Impella Pre or Post PCI
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Outcome By Support Strategy
Survival to discharge
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Conclusions
• Impella & IABP are most frequently used hemodynamic support devices in the cath lab that facilitate performance of high-risk elective PCI & during cardiogenic shock
• Impella provides better balance of efficacy, safety & feasibility during high risk PCI & provides superior hemodynamic support compared to IABP, especially if placed pre-PCI