Henriques_edit.qxp 25/7/08 09:47 Page 34
Heart Failure Ventricular Assist Devices
Percutaneous Mechanical Assist for Acute ST Elevation Myocardial Infarction
a report by
José PS Henriques
Director, Catheterisation Laboratory, Academic Medical Centre, University of Amsterdam
Despite considerable improvements in the treatment of acute ST by pharmacological therapy. This indication is listed in the
elevation myocardial infarction (STEMI), outcomes have predominantly American College of Cardiology (ACC)/American Heart Association
improved in STEMI patients without cardiogenic shock (CS). (AHA) guidelines as a class IB recommendation, although no
Nevertheless, cardiogenic shock occurs in approximately 7–10% of randomised controlled trials have been performed in CS. In our
STEMI patients and is the leading cause of death for hospitalised recently conducted, simultaneously performed meta-analysis of
patients. In-hospital mortality rates of STEMI complicated by CS are observational studies in STEMI patients with CS, data were significantly
around 50%, despite reperfusion by primary percutaneous coronary affected by confounders.
4
intervention (PCI), the current standard of treatment.
1
Currently, two
therapeutic approaches can be adopted for STEMI patients presenting Notwithstanding the lack of evidence to support the use of IABP
with CS or cardiogenic pre-shock to support the endangered therapy either in STEMI patients or in STEMI patients presenting with
circulation and the failing myocardium: CS, it is still a popular treatment strategy. Moreover, it is the only
method for mechanical cardiac assistance that is widely available and
• Pharmacological inotropic support: there is a variety of inotropic and easily applicable in current practice.
vasopressor agents enabling quick improvement of haemodynamic
parameters in CS. However, these agents failed to demonstrate Percutaneous Left Ventricular Assist Devices
improved survival in randomised studies. Currently, pharmacological Surgically implantable LV assist devices (LVADs) have been shown to
circulatory support is listed as a class IIA recommendation.
2
provide more effective circulatory support. However, in the setting of
STEMI complicated by CS, the applicability of this therapy is limited.
•Mechanical left ventricular (LV) support: this modality was made Therefore, the development of percutaneous LVADs has been of great
possible in humans first and foremost by the introduction of intra- interest. More recently, the TandemHeart and the Impella 2.5LP and
aortic balloon counterpulsation about four decades ago. Currently, the Impella 5.0LP have been introduced.
5
mechanical LV support with an intra-aortic balloon pump (IABP) is
listed as a class IB recommendation.
2
TandemHeart
The TandemHeart percutaneous ventricular assist device (pVAD) is an
Intra-aortic Balloon Pump extracorporeal, dual-chambered, centrifugal, continuous-flow pump. It
The IABP was first introduced in the setting of CS in 1968.
3
Ever since, is a left atrial to femoral artery bypass system, designed for short-term
and especially after the development of a percutaneous insertion mechanical LV support (see Figure 1). At a maximum rotational speed
technique, IABP therapy has been increasingly used for several clinical of 7,500rpm, the TandemHeart pVAD can deliver a maximum output
conditions requiring mechanical LV support. In current practice, it is of 4.0l/min. The device can be inserted in the catheterisation
still the most frequently used method of mechanical cardiac assistance laboratory, under fluoroscopy. The 21Fr trans-septal inflow cannula is
in the catheterisation laboratory. first inserted through the femoral vein and positioned in the left
atrium, guided by fluoroscopy. The outflow cannula (15–17Fr) is
Currently, the main indication for IABP therapy in STEMI – as inserted through the femoral artery and positioned at the level of the
adjunctive therapy to revascularisation – is CS not quickly reversed aortic bifurcation. The implantation procedure takes around 30–45
minutes, but there is a substantial learning curve.
José PS Henriques is Director of the Catheterisation
Laboratory at the Academic Medical Centre of the University
Two randomised trials comparing IABP with TandemHeart have been
of Amsterdam. He also leads the Academic Medical Centre
conducted in STEMI patients with CS. In both of these trials,
Mechanical support for Acute Congestive Heart failure in ST
haemodynamic parameters improved significantly in patients who
elevation myocardial infarction (STEMI) patients (AMC
MACH) programme. His particular field of interest is
were supported by the TandemHeart VAD. However, both small
concomitant strategies for acute myocardial infarction in the
studies revealed a high complication rate in the TandemHeart-
setting of primary angioplasty. Dr Henriques gained his MD
from the University of Amsterdam and his PhD in medicine
supported patients. Complications observed included tamponade,
from the University of Groningen. He completed his cardiology training at the Hospital de major bleeding, critical limb ischaemia, sepsis and arrhythmias. The
Weezenlanden in Zwolle and his fellowship in interventional cardiology at the Academic
most important factors contributing to these complications are likely
Medical Centre of the University of Amsterdam.
to be the highly invasive and complex insertion procedure and the
E:
j.p.henriques@amc.uva.nl
extracorporeal support method, combined with full high
anticoagulation. In a recent review article we performed a meta-
34 © TOUCH BRIEFINGS 2008
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116