Chapters Transcript Video Hemodynamic Support Dr. Ramin Alimard defines high-risk percutaneous coronary intervention and the goal of hemodynamic support. So my talk is about uh basically hemodynamic support in chip patients. Um And one of the things that I wanted to mention is as this uh program got off the ground and as we work through these, we learned, we've learned so much from the surgeons and I appreciate doctor Kemp being here and it's all about teamwork and uh multidisciplinary discussions about and about different options that these patients have that sometimes don't have uh good options and having highly trained colleagues like our nurses and the Cath lab techs and um other specialties like advanced heart failure, structural heart. Um And at the end of the day, everybody works together to try to achieve the best outcomes for patients and that's what it's all about. So as we talk about uh percutaneous hemodynamic support and high risk PC, I, we're gonna try to define what high risk PC I is. What are the goals of hemodynamic support? What are the options for protected PC I who needs it? And then if we have time, we'll talk about future directions and um some examples of what's possible uh in the cat lab. So as we know Coronary disease is a leading cause of morbidity and mortality in this country. And patients are presenting with more complex lesion, lots of comorbidities and we're getting better technology so we can hopefully help patients um feel better and live longer. And in the Cath Lab, at least there's been a paradigm shift with this concept of protected PC I which uh uses hemodynamic support to allow us to do some crazy things in the Cath Lab, things that we were never able to do before. So every day, I'm never amazed at what things we're able to do. Everything I learned or I was told not to do in the Cath Lab because it was surgical grade disease we do on a daily basis. And I think it's gonna um result in better outcomes in patients and selected patients that are appropriately selected for those procedures. So what happens during PC I and I always kid around about this with the surgeons. Um When you do, when you go through open heart surgery, most of the time you can turn off the engine and put them on a heart lung machine, then you can do whatever you need to do and then get him back during PC I, we have to work on the engine with the engine running. So we need support. So you wanna support the heart. So when you go in there and you try to fix the artery and actually the process of fixing the artery occ includes the vessel and sometimes includes it for a short period of time, sometimes longer. And during that time, the engine can stall. So you need help and that's where hemodynamic support comes in. Uh It's usually people that have multivessel disease, poor LV function. And uh what you have to remember is this these uh options for hemodynamic support are much larger caliber and larger um uh devices that require larger access sites. So they increase the risk of complications from these devices. And unfortunately, we still don't have any generally accepted guidelines of what a chip PC I is. And what makes us say, OK, this person should get hemodynamic support versus not. And we're trying to develop those databases. So um what is the definition of a chip patient or high risk PC I, we throw it around uh all the time and uh some of these things that you see um unprotected, left Maine somebody that's really shocky multivessel disease. They have valve disease. Um You kind of know it when you see it. Uh it's usually the patient who's been in the hospital for a week or two where their case has been canceled 34 days in a row and we'll show up and they say, hey, can you go see this patient and they're complex and you go by the room and there's 10 people sitting there wringing their hands and everybody wants this magic solution and then you pull up the films and you feel nauseated because how severe the blockage is. So, um, what is, uh, what we look at as we look? And, uh, Clint mentioned some of these things. Uh, these patients are complex and it's not just the coronary anatomy that makes them complex. Uh There's technical parts, so their coronary disease is complex. There's comorbidities, these patients who are older, sicker and then there's the hemodynamics. So people are shocky, they're in the IC U, they can't get their blood pressure up, they can't lay flat. So all that works in and it's really the intersection of those three general areas that defines what a chip patient is. Um And um I just put this in here to just to mention that when there is a surgical turn down patient, that patient is at very high risk for mortality, 6 to 7 times increase in mortality and risk of kidney failure. And if they're lower their ef is their mortality goes up. So some of these procedures are truly salvaged procedures. And then the other thing I want to mention is a high risk is not equal to complex. These patients are high risk and complex, but you can have high risk patient that doesn't have complex disease and you can have a sick patient that uh is not high risk. Um So what are the goals of hemodynamic support? Um So uh you wanna maintain adequate coronary perfusion, you wanna provide stable and effective blood pressure you want to improve the cardiac output, you want to unload the LV and you want to do all that with a low complication rate. So basically you want to support the engine with the engine running while you work on it. And the goals are to increase oxygen supply, decrease oxygen demand and increase cardiac power. So those are the three things as we go through these devices that you want to do and you have to balance that with the risk of these procedures. Um biggest risks being vascular complications, a hemorrhage, the devices can cause hemolysis. You can get thrombotic or embolic events. So it's always a balance uh risk benefit ratio. And as I said, larger access, larger the hole, the bigger the problem, we have to take these tubes out and you guys in the cath holding and in the IC US are stuck with these patients bleeding or having other complications. So, um and bleeding is associated with worse outcomes. So you have to use the right device and the right patient uh in the right time and there's a bunch of these devices, we'll go through them quickly. Some of the ones we most use and the level of support depends on what you use and the size of the um catheter you put in on all these is a little different. Um So as you go through this, the big uh broad strokes are you want to provide circulatory support, you want to provide ventricular support. You want to improve coronary perfusion, you want it to be easy to use and take out and you want to have relatively low risk of complications. So it's always a balance and you have to make choices. Uh We're not going to talk about cardiogenic shock or myocardial salvage. In this talk, we're paying primarily talking about protected PC I, high-risk PC I, how do we maintain adequate blood pressure and cardiac output uh when we oude the artery so that the patient doesn't have hemodynamic compromise and enable complete revascularization. So we can provide outcomes that are at least somewhat closer to what our surgeons have been providing for years. So, um in the Cath Lab, it feels like uh you're always putting out fires and it's really uh when the, when you start these cases, you're always looking. OK. So what's going on? And in the old days, um I would, before we had, we were fast out with these devices. Uh I would always say, ok, I hope if I can open that artery quickly enough, then the patient will get better and you would move fast, fast, fast. And what I've learned from Doctor Kemp and our cardiothoracic surgeons, you don't want to wait till the engine. Uh when the house is all burned down before you call for help, you want to start. And the paradigm has completely shifted now. So you want to put your support device in when the fire is just starting and then you'll have a much better chance of getting good outcomes. Um So the four main uh support devices that we use balloon pump and pellet tandem heart and um ECMO are the ones we're going to touch on. And just a quick uh summary here, uh The balloon pump provides a little bit of hedy support. That's all we used to have. It delivers maybe half a liter per minute of cardiac output. You put it in the aorta and it can unload the heart. It's small. So it's easy to use and remove with low risk of complications is a percutaneous L LDA flow pump that is 13 to 14 French uh for the ones we use in the Cath lab, but you can have a 21 French one that the cardiac surgeons implant through a cut down and you deliver 3 to 5 liters per minute of support and it is easy to use. Um The uh tandem heart PHP is like the, the tandem heart is uh in the venous system. It uh takes blood from, as we'll show from the left atrium into the aorta and it requires a trans P puncture. And the French size for the venus sheet is 21 and the arterial is somewhere between 15 and 17. And then ECMO is uh you're oxygenating the blood outside the body and you take blood from the right atrium and you deliver it to the aorta. So uh this is black and white for a reason, the intraortic balloon bomb uh Adrian Kantrowitz from Maman's Hospital in New York in 1967 which makes it as old as I am and it's been around and we still use it uh selectively. Um and it's uh decreases signs of myocardial ischemia. It can unload the heart, it can improve coronary perfusion. Um But as I said, it doesn't really give you much uh hemodynamic support. Uh We use it a lot for heart failure or for left main disease to get them to the or when you don't really need that much support and it's quick and easy to use. Uh aortic valve, insufficient insufficiency dissection or severe peripheral var disease would keep you from using it. It inflates in the aorta to push the blood back in the corna deflates the afterload, reduce you and um is relatively quick and easy. We use it much less than we did even 10 years ago. And that's because some of the bigger studies have shown that it may not change outcomes especially in shock. The impala is a bigger French device. It has a um it supports the circulation much better. It unloads, the ventricle increases cardiac output, decreases oxygen consumption, everything that we wanted it to do. You, you have to be careful if uh you can't use it in LD. Thrombus. Severe A S is a challenge although Dr Summers um has the ability to help us get it in the ventricle so we can use it. Um and uh aortic insufficiency and peripheral vascular disease are limitations. So the, the catheter has an inflow catheter in uh I inflow uh region in the left ventricle, it goes through this impeller pump and it delivers the blood into the aorta. And as I said, improves cardiac output, decreases oxygen supply. Uh oxygen demand, improves oxygen supply. So it's really, we're very familiar with using it. If the pressure is high, you need a gradient for it to work. So you don't want the pressure to be high. The tandem heart is requires venous access. That's a large bore access in the left atrium, takes uh um blood oxygenated blood from the left atrium and unloads the ventricle and delivers in the aorta. And uh it's a much bigger catheter, it unloads up to 80%. They'll be unloading and helps the heart recover, which is important. Um It improves the cardiac index, decreases the filling pressures and improves your blood pressure. And it has the main complications I would say are vascular site infections. Um and the extracorporeal membrane oxygenation, you're taking blood from the right atrium, delivering it back into the uh arterial system and you have oxygenation outside the body similar to a heart lung machine, but this device does not unload the ventricle. So that's a disadvantage of, of ECMO and sometimes we have to unload the ventricle with another device while you're using it to oxygenate. Um So, um and as I said here, uh ECMO increases your oxygen demand, decreases your oxygen supply, but does increase cardiac output and it oxygenates outside. Um So, um let's see. So, and then we have now evolving technologies as we talked about, um we have um uh ability with expandable sheets. So you can get a large board device into the vessel without creating a large bore hole. These are in studies that are ongoing. You have novel interior balloon pump and other percutaneous vats and then we have all the uh artificial intelligence stuff. So this is the newer impeller that's coming out. It's a smaller French 9 to 10 French. So that's a game changer for us because the risk of complications will go up and then patients that can benefit from it uh will increase. And uh I don't know if I can run this. Um Probably not in the interest of time I was going to show you. Yeah, there it goes. So you put the sheet in and all of a sudden a big huge pump comes out and then you can remove it. So ingenious, right? Biomedical engineering is going to change how we do things. So who needs mechanical circuitry support? Um As I said, you know, you kind of know it when you see it, but we use uh an atomic factors, patient comorbidities and looking at their hemodynamics and people are trying to come up with scoring systems just like the sts database. Although we don't have that data yet, we're trying to get that data. So this is one of the uh risk scores that's out there, a decision algorithm, a point system. So if based on those characteristics, if you only have one or two of them, you probably don't need support. If you, your score is more than four, you should consider support. And if you see on the bottom, um high risk for vascular injury and low hemoglobin are reasons not to use hemodynamic support because the risk of complication goes up. So, um so we can we, when I see a patient, I kind of go through this informally. If I'm really worried, I'll sit down and calculate it out, but most of us, it's somewhat of a gestalt. So when I go see a patient, I see him, I look at him, I say, OK, is this patient hemodynamically stable or unstable? If they're unstable? You have your answer. Uh I apologize about the pulmonary there. That's a misspelling. Number two. does the patient have the reserves to to tolerate a brief ischemic insult? And if they have borderline pressure, they have severe pulmonary hypertension. Uh last remaining conduit with the efo 10, you know that you're gonna need support. Uh Is the patient at risk uh during the interruption of the blood flow for hemodynamic collapse? If you think about it, you're gonna use hemodynamic support. Um And then the last question is uh if I have to do uh more involved things like retrograde PC, uh CTO PC I that Doctor Levine mentioned or if you have uh a proximal left main or last remaining vessel, you're gonna wanna use support. So um that's just the summary of the different effects of those that we had talked about. Um which I in the interest of time will go through. This is just a quick reminder of the heart team and decision making. If you look at the first graph on top, that's a comparison of the uh sts score. So if the sts score is low, these patients get surgery, that's the barring green. If the STSTS score is high, it falls to us. And then we have to make a decision whether this patient is going to benefit from PC I or is this a patient that needs palliative care? And those discussions are important and we use our hospital medicine colleagues palliative care and it's definitely a multidisciplinary approach. So in summary, um run a little late. So mechanical circulatory support requires a thoughtful consideration of indication and clinical person. What why you're doing it and what you want to accomplish. It's understanding the hemodynamics and uh problem is our fund of knowledge and evidence base is limited and there's a need for ongoing studies to help us define who would benefit and who wouldn't. So we're still learning, we're still collecting data. And um the protect four study where Doctor Levin is the P I is one of those randomized trials that we're involved in it to try to figure this out who is going to benefit and who's not. And uh so this is my final slide. High risks protected PC I is now possible and carefully selected patients with complex coronary disease with comorbidities that makes them not surgical candidates. And they really, these patients really have no other options. So that's either palliative care or we try to do something. But it's important to know that most complex PC I does not require hemodynamic support. Most of these patients we can get through without these fancy toys. Um Database for the outcomes are evolving. A selection of hemodynamic support device depends on the clinical features. An atomic features is there l the thrombus is area stenosis. How big a uh device can you put in their leg? And the most commonly used device in our center. And I would say most centers is the impala device that we're using now and with the newer device that's coming out that may be nine or 10 French compatible that will expand our ability to treat more and more patients with these support devices. Uh And as I mentioned, there's no single trigger that mandate support. It's a composite of your gut feeling, looking at the anatomy, the patient characteristics and the hemodynamics. Um And as we get better with our technology and as things get more miniaturized, we'll be able to help more patients. That's all I have as far I can show a couple of cases. But I think in the interest of time we should probably, um, this is a patient that had atherectomy of the left main with support. This is a case that's clearly a surgical case wasn't a surgical candidate due to a severe LV, dysfunction and with impala support, you can do crazy things, any uh questions or concerns. Published October 17, 2023 Created by Related Presenters Ramin Alimard, M.D. Sentara Cardiology Specialists View full profile
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