Abstract
The Impella Recover LP 2.5 (Abiomed, Danvers, MA, USA) is a ventricular assist device that is easily placed and has low adverse events. It helps unload myocardial demand and enables revascularization in patients who are otherwise at extreme risk for percutaneous coronary intervention (PCI). It breaks the cycle of cardiogenic shock and is indicated in patients with low ejection fraction (EF), acute heart failure, and concurrent high-risk factors for intervention or surgery. Many case reports have been published regarding use of this device in high-risk PCIs, but successful intervention in two high-risk vessels in one setting has rarely been reported. We describe such a case report here where two critical lesions in LAD and circumflex arteries were successfully intervened on with the assistance of this device.
1
Introduction
High-risk percutaneous coronary interventions (PCIs) in patients with already low ejection fraction (EF) could easily result in complications including coronary hypoperfusion, heart failure, and hemodynamic collapse . Stabilization with a prophylactic device may help in these scenarios. The Impella Recover LP 2.5 is a new percutaneous left ventricular (LV) assist device, which basically pumps blood from the LV, across the aortic valve into the ascending aorta . It helps unload the LV and improves coronary perfusion . The intra-aortic balloon counterpulsation, which is the most commonly used LV support device , can only modestly augment cardiac output. On the other hand, the Impella delivers 2.5 l/min of cardiac output. It is easy to use and with no major complications. A preprocedure echo should rule out LV thrombus . Safety and feasibility of the use of this LV assist device in cardiac interventional procedures have been reported . These devices are used in patients who otherwise may not undergo PCIs due to their high-risk category or are high-surgical-risk candidates. This would usually involve patients with low EF, recent acute events and heart failure, concurrent high intervention risks, and surgical risks.
We describe successful PCIs in two severely diseased vessels in a patient with EF of <30% and he was 1 month after a massive MI which resulted in cardiogenic shock. He had a long 100% occlusion in LAD and severe circumflex disease and with the severity of his situation would not easily undergo intervention in both the vessels.
2
Case study and procedure report
A 62-year-old male initially presented with acute cardiogenic shock and his electrocardiogram suggested anterior myocardial infarction and his cardiac biomarkers were positive. The patient was found to have a large acute anterior non–ST-elevation myocardial infarction. His cardiac catheterization at that time showed severe long disease in the left anterior descending artery (LAD), severe coronary disease in right and circumflex, anterior akinesis, and EF was 20–25%. Thrombus from LAD was aspirated and patient received three Promus stents (Boston Scientific, Natick, MA, USA) into the LAD. Angiomax infusion was used around the procedure time. He was ultimately discharged on appropriate medications including aspirin and plavix with a plan to do staged intervention of the circumflex disease later. One month later, he presented with angina and symptoms of acute exacerbation of chronic congestive systolic heart failure. Cardiac catheterization at this time showed severe coronary disease in the right circumflex (90% stenosis in a small vessel) and LAD (100% occlusion from distal third all the way to the apex). Due to his low EF and recent MI and cardiogenic shock and current acute heart failure symptoms, the decision was made to use the Impella device to assist PCI in LAD and circumflex.
The patient had severe left-sided peripheral disease, so through the right groin a right Judkins was exchanged for a Platinum Plus wire (Boston Scientific) and the Impella device was installed in the left ventricle with a good cardiac output of 2.5 l ( Fig. 1 ). An echocardiogram done the previous day confirmed that he had no apical thrombus and so we felt this procedure would be safe.
We went into the left groin using a JL4 guide to cross the 100% occlusion in the LAD. The Cougar (Medtronic, Minneapolis, MN, USA) wire and a FineCross catheter (Terumo, Somerset, NJ, USA) were used, but could not get across the 100% occlusion. We eventually crossed the occlusion with an exchange length Whisper wire (Abbott Vascular, Abbott Park, IL, USA) into the apical segment of the LAD. The vessel was 100% occluded all the way to the apex of the LAD artery. We felt that this was more of a chronic occlusion than a thrombotic occlusion; however, even before ballooning with a 2.5×2-cm-long balloon, just with crossing it with the catheter, we could see the vessel to be patent and it looked like a flap had basically made the vessel occlusive. The restoration of flow was TIMI-3; however, an angiogram suggested there was diffuse disease or a thrombus distally present in the vessel. With the thought that it could be thrombus, we passed the Pronto (Vascular Solutions, Minneapolis, MN, USA) device to the apex and pulled out two syringes full of fluid. However, it did not appear to have any material in it other than blood. With this flap, without any material coming out of the Pronto, we placed a 2.5×30 mm Endeavor stent (Medtronic) and deployed to 14 atm. He previously had Promus stents (Boston Scientific) placed in the LAD at the time of the acute myocardial infarction. TIMI-3 flow was noted afterwards with residual stenosis of 0%. We did notice a very small distal branch of the LAD where the Whisper wire had literally doubled over. Here we noted perivascular staining that immediately cleared. As the staining immediately cleared and as the patient was hemodynamically stable, we went ahead to work on the circumflex.
With difficulty, we put in a Whisper wire down to the circumflex where it was 90% stenosed proximally with two small obtuse marginal branches 90% stenosed. The Whisper wire got down, but with difficulty, so we exchanged the support catheter, took the wire out and replaced it with a Platinum Plus (Boston Scientific) wire. We performed balloon angioplasty in proximal vessel with 2.5×10 mm balloon and distal vessels with a 2.5×10 mm balloon and placed a 3.0×2.5-mm Endeavor stent (Medtronic). At this time, the patient was clearly hypotensive and we started him on Neo-Synephrine and an echocardiogram confirmed tamponade. We placed a pericardial needle and took out 1500 ml of bloody fluid with resolution of his hypotension. Now with the support device he had a blood pressure of 130/70 and returned to the coronary care unit (CCU) with the Impella device in place. Fig. 2 depicts the angiographic results before ( Fig. 2 A) and after intervention ( Fig. 2 B). With the occlusion of the LAD stent, we doubled the dose of Plavix to 150 mg/day. During the second procedure, we began Angiomax which we immediately discontinued after the tamponade was noted. The Impella device was removed in the CCU. He was discharged 2 days later. One month later, his EF was 45%.
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