Percutaneous Life Support: Is It Safe to Plug and Play?

In this issue of the Journal of Invasive Cardiology, Dr. Bagai et al¹ from Vanderbilt have presented their single-center experience with percutaneous life support in a highly heterogeneous and clinically at-risk population. They describe their participation with the use of a percutaneous left ventricular assist device (pLVAD) and percutaneous cardiopulmonary bypass support (CPS) in both elective and emergent subgroups, as well as a variety of coronary, valvular and structural heart disease scenarios. The elective group consisted of those requiring percutaneous coronary intervention (PCI) of an unprotected left main/left main-equivalent anatomy, PCI on the last remaining vessel, multivessel PCI with rotational atherectomy or aortic valvuloplasty in the setting of depressed ejection fraction (EF). The emergent group consisted of patients with refractory cardiogenic shock or in-laboratory cardiac arrest as a bridge to LVAD/transplantation. The authors need to be congratulated on their case series, which focuses on safety and efficacy endpoints in a sample of patients who represent real-world clinical scenarios. The therapeutic goal for percutaneous circulatory support or pLVAD support is to restore or maintain normal hemodynamics and organ perfusion in cardiogenic shock or to serve as support for high-risk PCI. Although there are a variety of devices with different mechanisms of left ventricular assistance, all have beneficial effects of acute left ventricular unloading as well as theoretically maintaining peripheral organ and skeletal muscle perfusion. Historically, intra-aortic balloon counterpulsation was the method of choice for mechanical assistance and hemodynamic stabilization in this high-risk population. This method has proven less useful in patients with persistent myocardial dysfunction, and once shock develops, the mortality rate remains higher than 50%.² A mechanical device that is able to rapidly restore adequate circulatory support, as well as being fairly quick to implant, has undoubtedly generated a significant amount of interest as well as numerous single-center and smaller randomized trials. Despite the emerging interest and increasing numbers of institutions utilizing percutaneous support, questions remain concerning cost effectiveness, rapidity of placement, complication rates and proper patient selection. Numerous studies have delineated a considerable range of implantation times, which is commonly dependent upon experience with the device as well as mobilization of the appropriate multidisciplinary team. This requires a collaborative effort among many disciplines including, but not limited to, cardiology, cardiac surgery, anesthesia and nursing. The current trials discuss varying complications ranging from bleeding, infection, limb ischemia, paradoxical embolism and cardiac tamponade. As the technology continues to evolve for these devices, a more expansive risk-benefit ratio will emanate along with larger, comparative randomized trials. As elegantly delineated in this series, the authors were able to demonstrate safety and efficacy in their patient subgroups despite a high prevalence of preprocedural critical state markers. The incidents of death, major adverse cardiac events, bleeding and lower-extremity ischemia were comparable to previously published data with similar patient sizes and characteristics. Although current studies collectively portend a trend towards the use of these devices, questions remain regarding the short-term clinical benefit as well as the long-term effect on current management strategies.

References

1. Bagai J, Webb D, Kasabeh E, et al. Efficacy and safety of percutaneous life support during high risk percutaneous coronary intervention, refractory cardiogenic shock and in-laboratory cardiopulmonary arrest. J Invasive Cardiol 2011;23:141–147.
2. Hochman, JS. Cardiogenic shock ccomplicating acute myocardial infarction: Expanding the paradigm. Circulation 2003:107:2998–3002.

———————————————————— From the Department of ^*Hines VA Cardiology and the ^£Department of Cardiology, Vascular Medicine and Peripheral Interventions, West Virginia University, Charleston, West Virginia, and ^§Interventional Cardiology Research, Loyola University, Stritch School of Medicine, Maywood, Illinois. Disclosure: Dr. Dieter: Speakers bureau for Bristol-Myers Squibb and Daiichi Sankyo. Address for correspondence: Robert S. Dieter, MD, RVT, Assistant Professor, Department of Medicine, Loyola University, Stritch School of Medicine, 2160 S. First Avenue, Bldg. #110, Room #6289, Maywood IL 60153. Email: rdieter@lumc.edu