First Successful Use of 2 Axial Flow Catheters for Percutaneous Biventricular Circulatory Support as a Bridge to a Durable Left Ventricular Assist Device
2015; Lippincott Williams & Wilkins; Volume: 8; Issue: 5 Linguagem: Inglês
10.1161/circheartfailure.115.002374
ISSN1941-3297
AutoresNavin K. Kapur, Marwan Jumean, Adel Ghuloom, Nima Aghili, Caitlin Vassallo, Michael S. Kiernan, David DeNofrio, Duc Thinh Pham,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculation: Heart FailureVol. 8, No. 5First Successful Use of 2 Axial Flow Catheters for Percutaneous Biventricular Circulatory Support as a Bridge to a Durable Left Ventricular Assist Device Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBFirst Successful Use of 2 Axial Flow Catheters for Percutaneous Biventricular Circulatory Support as a Bridge to a Durable Left Ventricular Assist Device Navin K. Kapur, MD, Marwan Jumean, MD, Adel Ghuloom, MD, Nima Aghili, MD, Caitlin Vassallo, MSc, Michael S. Kiernan, MD, David DeNofrio, MD and Duc Thinh Pham, MD Navin K. KapurNavin K. Kapur From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , Marwan JumeanMarwan Jumean From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , Adel GhuloomAdel Ghuloom From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , Nima AghiliNima Aghili From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , Caitlin VassalloCaitlin Vassallo From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , Michael S. KiernanMichael S. Kiernan From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. , David DeNofrioDavid DeNofrio From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. and Duc Thinh PhamDuc Thinh Pham From The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA. Originally published1 Sep 2015https://doi.org/10.1161/CIRCHEARTFAILURE.115.002374Circulation: Heart Failure. 2015;8:1006–1008During the past 2 decades, the use of durable mechanical circulatory support (MCS) for advanced heart failure has grown exponentially, in large part, because of clinical trials demonstrating improved rates of survival when compared with medical therapy alone.1 Among patients referred for durable MCS implantation, 2 major predictors of poor survival include (1) clinical instability identified as Interagency for Mechanically Assisted Circulatory Support profiles 1 or 2 and (2) preoperative right ventricular failure.2,3 Right ventricular failure also currently prohibits the use of durable MCS as a destination therapy option. In parallel to growth in durable MCS implants, nondurable or percutaneous MCS device use has also increased since 2007.4 No reports have described the use of percutaneously delivered axial flow catheters to fully support both right and left ventricular (LV) functions before durable MCS implantation. We describe a case illustrating the potential use of axial flow catheters to support a patient with cardiogenic shock caused by biventricular failure (BiVF).A 45-year-old man with stage D ischemic cardiomyopathy and a LV ejection fraction of 10%, moderate RV dysfunction, and moderate tricuspid regurgitation presents with 1 month of worsening dyspnea without chest pain. A recent coronary angiogram confirmed no revascularization option. On the basis of initial hemodynamics (Table), we initiated milrinone. Within 6 hours, the patient developed ventricular fibrillation requiring a single defibrillation without cardiopulmonary resuscitation. To improve cardiac output, an intra-aortic balloon pump was implanted and milrinone continued. Within 4 hours, he continued to decline with worsening dyspnea, hemodynamic indices, and renal function. Echocardiography confirmed severe BiVF (Movies I and II in the Data Supplement). A multidisciplinary discussion determined that the patient was a potential candidate for orthotopic heart transplantation pending completion of his transplant evaluation and improved clinical stability. Durable MCS was deferred because of clinical instability with impaired end-organ function and uncertainty about committing him to surgical biventricular devices without transplant candidacy being defined. Nondurable MCS using venoarterial extracorporeal membrane oxygenation was considered; however, his oxygenation was stable and this strategy would limit our ability to remove RV support if the RV recovered function either before or after LV assist device (LVAD) implantation. We elected to proceed with simultaneous biventricular axial flow catheter support using the Impella 5.0 LP and Impella RP (Abiomed Inc, Danvers, MA) devices.Table. HemodynamicsMilrinoneMilrinone+IABPPost-Bi-Pella Day 1Post-Bi-Pella Day 5Post-HM-II (RP Out)Right atrial pressure, mm Hg202610153PA pressure, mm Hg44/2842/2625/1922/1822/12PA occlusion pressure, mm Hg2420151010Mixed venous saturation, %4642676868Arterial saturation, %9999999999Mean arterial pressure, mm Hg6565827874Serum creatinine, mg/dL0.81.81.850.850.81Bi-Pella indicates Biventricular Impella; HM-II, HeartMate-II; IABP, Intra-aortic balloon pump; and PA, pulmonary artery.A 10-mm vascular graft was anastomosed to the right axillary artery, and the Impella 5.0 LP device was delivered into the LV. Device activation achieved 5.0 L/min of flow at power level 8 (P8) resulting in reduced LV pressures and increased mean aortic pressure (Figure 1A; Table). Central venous pressure increased after initiating LV support alone. Next, the Impella RP device was delivered via the right femoral vein into the pulmonary artery. Activation of the Impella RP at 3.4 L/min at P6 reduced the central venous pressure and increased both LV diastolic pressure and mean arterial pressure (Figure 1B; Table). Biventricular Impella (Bi-Pella) support was continued for 5 days followed by implantation of a HeartMate-II LVAD (Thoratec Inc). Estimated RP flow ranged between 3.4 and 4.2 L/min and was titrated to maintain an LP flow of 4.9 to 5.1 L/min. The Impella RP was left in place for 3 days after LVAD implantation followed by removal with manual venous compression only (Figure 2). The patient was successfully discharged to home on hospital day 15 without inotropic therapy.Download figureDownload PowerPointFigure 1. Hemodynamic tracings of left ventricular (LV) and aortic (Ao) pressures. A, †Activation of the Impella 5.0 LP device reduces LV systolic and diastolic pressures, reduces aortic pulse pressure, and increases mean aortic pressure. B, Central venous pressure (CVP) also increases and a pulsus paradoxus (arrows) consistent with right ventricular pressure overload is noted in the aortic pressure tracing after 15 min of Impella 5.0 support alone. ‡Activation of the Impella RP device restores LV preload and therefore increases LV systolic and diastolic pressures, increases mean aortic pressure, and decreases CVP. The pulsus paradoxus resolves after the patient is on Bi-Pella support (†‡) with the both Impella 5.0 LP and RP devices activated simultaneously.Download figureDownload PowerPointFigure 2. Fluoroscopic and radiographic images showing (A) positioning of the Impella 5.0 LP and Impella RP axial flow catheters, (B) ongoing support with the Impella RP device after implantation of a HeartMate-II (HM-II) left ventricular assist device (LVAD), and (C) predischarge image of the HM-II LVAD alone.BiVF remains a major clinical challenge when evaluating patients for durable MCS. Venoarterial extracorporeal membrane oxygenation can temporarily stabilize patients, but it is limited by the inability to selectively support 1 ventricle at a time before or after LVAD implantation. Biventricular support with extracorporeal centrifugal pumps require either surgical cannulation via a thoracotomy or a trans-septal puncture into the left atrium. In this report, we describe the first successful use of 2 axial flow catheters in the LV and RV to provide full biventricular support before LVAD implantation. We further show that supporting the LV alone can worsen RV hemodynamics in the setting of BiVF and that preprocedural planning for simultaneous biventricular support provides hemodynamic stability. Furthermore, continued use of the RV support catheter after LVAD implantation allows for ongoing RV recovery and removal of the RV device without the need for durable RV MCS. These findings suggest that Bi-Pella is a feasible percutaneous approach for BiVF, especially among patients who are poor or unclear candidates for durable MCS.DisclosuresDrs Kapur and Pham receive research support, consulting fees, and speaker honoraria from Abiomed, Heartware, or Thoratec. Drs Kiernan and Ghuloom receive consulting fees and speaker honoraria from Heartware and Thoratec The other authors reports no conflicts.FootnotesGuest Editor for this article was Douglas L. Mann, MD.The Data Supplement is available at http://circheartfailure.ahajournals.org/lookup/suppl/doi:10.1161/CIRCHEARTFAILURE.115.002374/-/DC1.Correspondence to Navin K. Kapur, MD, The Cardiovascular Center, Tufts Medical Center, 800 Washington St, Box 80, Boston, MA 02111. E-mail [email protected]References1. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume ED, Miller MA, Timothy Baldwin J, Young JB.Sixth INTERMACS annual report: a 10,000-patient database.J Heart Lung Transplant. 2014; 33:555–564. doi: 10.1016/j.healun.2014.04.010.CrossrefMedlineGoogle Scholar2. Kirklin JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, Miller MA, Timothy Baldwin J, Young JB.Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients.J Heart Lung Transplant. 2013; 32:141–156. doi: 10.1016/j.healun.2012.12.004.CrossrefMedlineGoogle Scholar3. Kormos RL, Teuteberg JJ, Pagani FD, Russell SD, John R, Miller LW, Massey T, Milano CA, Moazami N, Sundareswaran KS, Farrar DJ; HeartMate II Clinical Investigators. Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: incidence, risk factors, and effect on outcomes.J Thorac Cardiovasc Surg. 2010; 139:1316–1324. doi: 10.1016/j.jtcvs.2009.11.020.CrossrefMedlineGoogle Scholar4. Stretch R, Sauer CM, Yuh DD, Bonde P.National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis.J Am Coll Cardiol. 2014; 64:1407–1415. doi: 10.1016/j.jacc.2014.07.958.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Weber M, O'Malley T, Choi J, Maynes E, Prochno K, Austin M, Wood C, Patel S, Morris R, Massey H and Tchantchaleishvili V (2020) Outcomes of percutaneous temporary biventricular mechanical support: a systematic review, Heart Failure Reviews, 10.1007/s10741-020-09971-7, 27:3, (879-890), Online publication date: 1-May-2022. DeFilippis E, Topkara V, Kirtane A, Takeda K, Naka Y and Garan A (2022) Mechanical Circulatory Support for Right Ventricular Failure, Cardiac Failure Review, 10.15420/cfr.2021.11, 8 Montisci A, Sala S, Maj G, Cattaneo S and Pappalardo F (2022) Comprehensive evaluation of Impella RP ® in right ventricular failure , Future Cardiology, 10.2217/fca-2021-0075, 18:4, (285-298), Online publication date: 1-Apr-2022. Belluschi I, Denti P, Buzzatti N, Melisurgo G, Ajello S, Ancona M, Bertoglio L, Stella S, Agricola E, Alfieri O, Castiglioni A, De Bonis M and Scandroglio A (2021) Complicated Bi-Pella Support: Acute Mitral Regurgitation and Bailout MitraClip Repair, Structural Heart, 10.1080/24748706.2020.1852355, 5:1, (99-100), Online publication date: 1-Jan-2021. Desai S and Hwang N (2020) Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2019.08.024, 34:1, (208-218), Online publication date: 1-Jan-2020. Tschöpe C, Van Linthout S, Klein O, Mairinger T, Krackhardt F, Potapov E, Schmidt G, Burkhoff D, Pieske B and Spillmann F (2018) Mechanical Unloading by Fulminant Myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA Concepts, Journal of Cardiovascular Translational Research, 10.1007/s12265-018-9820-2, 12:2, (116-123), Online publication date: 1-Apr-2019. Grechishkin A, Mayngart S, Nekrasov A, Fedorchenko A and Porhanov V (2019) MECHANICAL CIRCULATORY SUPPORT IN PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION, Complex Issues of Cardiovascular Diseases, 10.17802/2306-1278-2019-8-1-100-111, 8:1, (100-111) Albulushi A, Giannopoulos A, Kafkas N, Dragasis S, Pavlides G and Chatzizisis Y (2018) Acute right ventricular myocardial infarction, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2018.1489234, 16:7, (455-464), Online publication date: 3-Jul-2018. Pappalardo F, Scandroglio A and Latib A (2018) Full percutaneous biventricular support with two Impella pumps: the Bi-Pella approach, ESC Heart Failure, 10.1002/ehf2.12274, 5:3, (368-371), Online publication date: 1-Jun-2018. Konstam M, Kiernan M, Bernstein D, Bozkurt B, Jacob M, Kapur N, Kociol R, Lewis E, Mehra M, Pagani F, Raval A and Ward C (2018) Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association, Circulation, 137:20, (e578-e622), Online publication date: 15-May-2018. Hanson I and Goldstein J (2018) Invasive Hemodynamic Assessment of Shock and Use of Mechanical Support for Acute Left and Right Ventricular Failure Hemodynamic Rounds, 10.1002/9781119095651.ch22, (401-407) Takeda K, Garan A, Ando M, Han J, Topkara V, Kurlansky P, Yuzefpolskaya M, Farr M, Colombo P, Naka Y and Takayama H (2017) Minimally invasive CentriMag ventricular assist device support integrated with extracorporeal membrane oxygenation in cardiogenic shock patients: a comparison with conventional CentriMag biventricular support configuration, European Journal of Cardio-Thoracic Surgery, 10.1093/ejcts/ezx189, 52:6, (1055-1061), Online publication date: 1-Dec-2017. Kuchibhotla S, Esposito M, Breton C, Pedicini R, Mullin A, O'Kelly R, Anderson M, Morris D, Batsides G, Ramzy D, Grise M, Pham D and Kapur N (2017) Acute Biventricular Mechanical Circulatory Support for Cardiogenic Shock, Journal of the American Heart Association, 6:10, Online publication date: 11-Oct-2017. Esposito M, Bader Y, Pedicini R, Breton C, Mullin A and Kapur N (2017) The role of acute circulatory support in ST-segment elevation myocardial infarction complicated by cardiogenic shock, Indian Heart Journal, 10.1016/j.ihj.2017.05.011, 69:5, (668-674), Online publication date: 1-Sep-2017. Renard B, Hanson I and Goldstein J (2016) Severe mitral regurgitation and biventricular heart failure successfully treated with biventricular percutaneous axial flow pumps as a bridge to mitral valve surgery, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26496, 89:1, (159-162), Online publication date: 1-Jan-2017. Spratt J, Raveendran G, Liao K and John R (2016) Novel percutaneous mechanical circulatory support devices and their expanding applications, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2016.1214573, 14:10, (1133-1150), Online publication date: 2-Oct-2016. Briceno N, Kapur N and Perera D (2016) Percutaneous mechanical circulatory support: current concepts and future directions, Heart, 10.1136/heartjnl-2015-308562, 102:18, (1494-1507), Online publication date: 15-Sep-2016. Aghili N, Bader Y, Vest A, Kiernan M, Kimmelstiel C, DeNofrio D and Kapur N (2016) Biventricular Circulatory Support Using 2 Axial Flow Catheters for Cardiogenic Shock Without the Need for Surgical Vascular Access, Circulation: Cardiovascular Interventions, 9:6, Online publication date: 1-Jun-2016. Atkinson T, Ohman E, O'Neill W, Rab T and Cigarroa J (2016) A Practical Approach to Mechanical Circulatory Support in Patients Undergoing Percutaneous Coronary Intervention, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2016.02.046, 9:9, (871-883), Online publication date: 1-May-2016. Morine K and Kapur N (2016) Percutaneous Mechanical Circulatory Support for Cardiogenic Shock, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-015-0426-6, 18:1, Online publication date: 1-Jan-2016. September 2015Vol 8, Issue 5 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.115.002374PMID: 26374919 Manuscript receivedJune 1, 2015Manuscript acceptedAugust 3, 2015Originally publishedSeptember 1, 2015 Keywordsshock, cardiogenicventricular function, leftarterial pressurecentral venous pressureheart-assist devicesPDF download Advertisement SubjectsCongenital Heart DiseaseHeart Failure
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