It has been shown that extracorporeal membrane oxygenation (ECMO) may provide cardiopulmonary support during percutaneous coronary interventions (PCI) in patients with refractory cardiogenic shock. Current guidelines consider ECMO and implantable left ventricular assist devices in selected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients. High-risk PCI remains a viable revascularization strategy for those patients who are not suitable for surgery or those refusing it. However, such a subset of patients is considered to be at an extremely high risk of PCI complications as there is a risk of hemodynamic collapse during balloon inflations or complex procedures, particularly, if coronary dissection with vessel closure or no reflow occurs. This chapter is devoted to the use of ECMO support for high-risk complex PCI in NSTE-ACS patients without cardiogenic shock based on the theoretical rationale, observational retrospective single-center studies and clinical case examples.
Aim . To analyze the multicenter international experience of high-risk protected percutaneous coronary intervention (PCI) procedures using the transaortic temporary pulsatile mechanical circulatory support (MCS) device iVAC 2L (PulseCath B. V., Amsterdam, the Netherlands). Material and methods . The pilot prospective-retrospective international multi-center observational study included patients with multivessel and/or complex coronary lesions, indications for coronary revascularization and refusal of the heart team from coronary artery bypass grafting and unprotected PCI due to a high risk of complications. PCI was performed with a temporary MCS using the iVAC 2L device in five clinics in Russia and Belarus. Results . From February 2023 to February 2024, 24 patients were included in the study. The median age was 69,0 years (interquartile range (IQR): 63,5-71,8); 87,5% were men. Twenty patients (83,3%) underwent elective PCI and four patients (16,7%) due to acute coronary syndrome (ACS) as follows: three with non-ST-segment elevation myocardial infarction and one with ST-segment elevation myocardial infarction (STEMI). The patient with STEMI underwent PCI against the background of acute heart failure (AHF). The median MCS time was 66,0 min (IQR: 43,0-98,0). Technical success of PCI was achieved in 100% of patients. The median initial and residual SYNTAX scores were 35,0 (IQR: 25,6-41,4) and 8,0 (IQR: 5,0-17,5), respectively. The median left ventricular ejection fraction before PCI and 7 days after was 44,0% (IQR: 31,0-54,0) and 48,0% (IQR: 36,5-53,5), respectively. In two cases (8,3%), major bleeding from the access site of the MCS device was observed. There were 2 fatal outcomes as follows: during elective PCI due to progression of acute left ventricular failure and in the late period due to septic shock after emergency PCI. Conclusion . PCI with MCP by the iVAC 2L device is an applicable and relatively safe tactic of coronary revascularization in patients with a high risk of complications, including in the conditions of ACS and AHF.
ГИБРИДНАЯ СТРАТЕГИЯ РЕВАСКУЛЯРИЗАЦИИ МИОКАРДА В СРАВНЕНИИ С АОРТОКОРОНАРНЫМ ШУНТИРОВАНИЕМ У ПАЦИЕНТОВ С МНОГОСОСУДИСТЫМ ПОРАЖЕНИЕМ КОРОНАРНОГО РУСЛА ПРИ СТАБИЛЬНОЙ ИШЕМИЧЕСКОЙ БОЛЕЗНИ СЕРДЦА, 30-ДНЕВНЫЕ РЕЗУЛЬТАТЫ
Aim. To assess the association of efficacy and safety endpoints with simultaneous carriage of polymorphic variants of the gene CYP2C19: rs4244285 (*2), and rs12248560 (*17) in treatment with clopidogrel. Material and methods. In the study, 289 patients included, from large cities of Siberia, underwent coronary stenting for acute coronary syndrome. All participants were assessed for alleles CYP2C19*2, *3, *17, and clinical outcomes were followed for 30 days (thrombotic complications, bleedings). Results. It was found that simultaneous carriage of CYP2C19*2 and CYP2C19*17 alleles is associated with the risk of serious adverse events development of thrombotic origin comparing to the absence of such polymorphism carriage (p=0,016), and with general adverse events risk related to insufficiency of clopidogrel action (р=0,046). Conclusion. According to the study results, subjects with the *2/*17 carriage should be classified to a delayed clopidogrel metabolism group, as in the group definite and probable stent thrombosis were found significantly more prevalent.
We report a successful antegrade recanalization of a 67-year-old male who survived cardiopulmonary resuscitation after a non-ST elevation acute myocardial infarction. The patient experienced cardiac arrest due to ventricular fibrillation after admission in hospital and he was stabilized after 25 min of cardiopulmonary resuscitation. After resuscitation no neurological symptoms were detected. Coronary angiography revealed in chronic total occlusions (CTO) three-vessels with severe coronary calcifications ( Panels D and E ); the patient was not considered to be a surgical candidate due to his poor clinical condition [very low ejection fraction (EF) <20% and acute coronary syndrome …
Analysed herein are the in-hospital and remote (12 months) results of transcutaneous coronary interventions (TCI) carried out in patients with non-ST elevation acute coronary syndrome (nSTE-ACS) and multivessel coronary artery disease with the use of extracorporeal membrane oxygenation (ECMO). From 2013 to 2015, the study included a total of 18 patients with nSTE-ACS and multivessel coronary artery disease who had been denied "open" surgical myocardial revascularization. The mean values (scores) of the scales in the group were as follows: GRACE - 119.7±67.6, SYNTAX Score - 33.5±8.1, Euroscore II - 5.2±21.9. The ejection fraction was averagely moderately low - 49.3±19.4%. During the in-hospital stay of the patients and 12 months after TCI we assessed the major adverse cardiovascular events (MACE): death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization of the target vessel - both as separate parameters and in a composite form. Additionally, we analysed perioperative and in-hospital complications, their structure, the volume of replacement therapy with blood components and the length of hospital stay. During the in-hospital period and at 12 months of follow up, the composite number of cases of adverse cardiovascular events amounted to 1 (5.5%) and 3 (16.5%), respectively. One patient died during in-hospital treatment and one more lethal outcome was registered by 12 months of follow up; hence, the mortality rate amounted to 1 (5.5%) and 2 (11%) cases, respectively. Stroke was observed in 1 (5.5%) patient only during the in-hospital period. No repeat revascularisation of the target vessel was performed. By the end of the hospital stay, BARC type 3-5 haemorrhagic complications were observed in 50% of patients. The in-hospital and remote (12 months) results of high-risk TCI with ECMO support in patients with nSTE-ACS and multivessel coronary artery disease, who had been denied surgical revascularization demonstrated an acceptable level of unfavourable outcomes. This approach may be regarded as a method alternative to revascularization and used in an utterly severe cohort of patients.
Purpose of the study : to evaluate the organoprotective effects of veno-arterial extracorporeal membrane oxygenation and intra-aortic balloon pump during high-risk percutaneous coronary intervention in acute coronary syndrome. Materials and methods . Patients required mechanical circulatory support ( n =51) were divided into two study groups: patients who received mechanical circulatory support by veno-arterial extracorporeal membrane oxygenation (ECMO) (Group 1, n =29) during high-risk percutaneous coronary intervention, and Group 2 patients who received mechanical circulatory support by intra-aortic balloon pump (IABP) during high-risk percutaneous coronary intervention (Group 2, n =22). The dynamics of instrumental parameters and laboratory markers of organ damage were evaluated by electrocardiography, echocardiography, determining troponin I, creatine phosphokinases and creatinine levels, NGAL, venous blood saturation to compare the organoprotective properties of mechanical circulation support in the intra- and postoperative period. Results . The following values of the parameters were found the next day after the intervention: troponin I — 0.18 (0.1; 2.3) ng/ml in the ECMO group and 1.64 (0.92; 2.36) ng/ml in the IABP group ( P =0.045); serum NGAL —139.4 (88.1; 166.7) ng/ml in the ECMO group and 212.3 (102; 279) in the IABP group ( P =0.027); renal dysfunction (stages R, I, F according to RIFLE) — 2 (6.8%) observations in the ECMO group and 7 (31.8%) in the IABP group (P=0.021); multiple organ failure (2 or more points according to SOFA) — 3 (10.3%) cases in the ECMO group and 12 (54.5%) in the IABP group ( P =0.001). Conclusion . Veno-arterial ECMO in comparison with IABP has a more pronounced organoprotective effect by achieving better hemodynamic stability, which, in turn, prevents hypoxia and the subsequent development of organ dysfunction. In addition, in conditions of veno-arterial ECMO, better completeness and quality of revascularization is ensured, and hospital mortality is also reduced.
Highlights Transcatheter aortic valve replacement is an innovative trend in modern cardiovascular surgery. This minimally invasive image-guided endovascular technology is becoming more and more safe, nowadays it can involve a minimalistic approach in which the aortic valve replacement is performed without incisions, anesthesia and cardiopulmonary bypass - patients are conscious and spontaneously breathing. The article describes a paradigm shift in modern cardiology, in which the concept of treating patients with degenerative aortic valve stenosis has changed over the 20 years of existence of the transcatheter replacement, starting as a method used only in small number of extremely high-risk patients unsuitable for cardiac surgery and now being the most prevalent treatment modality in patients at intermediate and even low surgical risk. The main clinical and technical principles of transcatheter aortic valve replacement, as well as the prospects for the development of this technique, are highlighted. Abstract Transcatheter aortic valve replacement technique was first implemented about 20 years ago, in April 2002. A quarter of a century ago, specialists involved in image-guided surgery would have never believed that they would perform transcatheter interventions on heart valves. Transcatheter interventions are an alternative to open-heart surgery for acquired heart disease. Transcatheter heart valve replacement or repeat transcatheter aortic valve replacement, which do not require incisions, cardiopulmonary bypass, and in some cases general anesthesia, to this day continue to be perceived as revolutionary and breakthrough, saving the lives of many patients. The article presents the main milestones in the development of image-guided endovascular surgery and transcatheter aortic valve replacement technique, the number of which in the United States and several European countries increases by 10–15% annually, reaching hundreds of thousands per year. The etiology and pathophysiology of aortic stenosis, the technique of transcatheter aortic valve replacement and the outcome of this promising minimally invasive procedure are presented.
