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Understanding the Principles of Continuous-Flow Rotary Left Ventricular Assist Devices

Introduction Mechanical circulatory support with durable left ventricular assist devices (LVADs) has become a mainstay therapy for treatment of advanced heart failure refractory to optimal medical management and has now surpassed cardiac transplantation as the most frequently utilized surgical therapy for treatment of end-stage heart failure. Important progress in the field has occurred with the introduction of continuous-flow (CF) rotary pump technology that has supplanted older…

The Role of Extracorporeal Membrane Oxygenation in Cardiac Support

Background The modern era of extracorporeal circulation began in the early 1950s, with cardiopulmonary bypass (CPB) used to support patients during open-heart operations for the repair of congenital heart defects. Over the course of the next two decades, improvements to the CPB circuits and oxygenator technology, especially the advent of the membrane oxygenator in the early 1970s, led to the development of extracorporeal membrane oxygenation (ECMO).…

Acute Circulatory Support

Introduction Cardiogenic shock (CS) is a state of insufficient cardiac output and end-organ perfusion that can be the terminal phase of many different cardiac conditions, including acute coronary syndromes, arrhythmias, progression of chronic cardiomyopathy, and acute cardiac dysfunction in the setting of idiopathic, traumatic, or inflammatory cardiomyopathies. This shock state is characterized by pathologic systemic vasoconstriction, impairment of tissue microcirculation, release of proinflammatory cytokines, and alterations…

Candidate Selection and Decision Making in Mechanical Circulatory Support

Introduction Deciding who should and who should not proceed with mechanical circulatory support (MCS)—including timing and device type—is one of the most difficult challenges in medicine. While there are now over 6 million people in the United States with heart failure (HF) and millions more worldwide, only a fraction of these patients will receive MCS. The reasons for this are multiple: patients die before MCS can…

Risk Stratification in Advanced Heart Failure

Introduction Risk factors or markers for mortality in heart failure (HF) include a long list of clinical parameters, including history, physical examination, laboratory values, hemodynamics, cardiac structure and function, and biomarkers ( Table 3.1 ). This chapter reviews predictors of survival in HF and compares acute versus chronic HF, HF with reduced ejection fraction (HFrEF), and preserved ejection fraction (HFpEF), as well as different subpopulations such…

Advanced Heart Failure and Cardiogenic Shock

Introduction The term shock first appeared in the English medical literature in a translation by John Clarke of a French treatise on gunshot wounds by Henry LeDran in 1740, Traité ou Reflexions Tirées de la Pratique sur les Playes d’armes à feu. In his translation, he used the English “shock” to translate the French word saisissement , which at that time might have meant “fright” or…

Historical Aspects of Mechanical Circulatory Support

Early mechanical circulatory support devices and technology development Establishing the Concept In the 1930s, Carrel and Lindbergh developed an in vitro artificial heart-like apparatus for keeping organs alive outside the body. They removed the hearts, kidneys, ovaries, adrenal glands, thyroid glands, and spleens of small animals to watch them develop and function over the course of several days. Acute animal studies in Russia and the United…

Equipment

Introduction Equipment is necessary for performing PCI. Although many operators would like to have everything available, the reality is that equipment cost and space limitations require prioritization. Here are some criteria to use when deciding the “must have” equipment for PCI: 1. At least one item that fulfills each of the requisite steps in PCI (e.g., obtaining access, engaging the coronary artery, assessing the coronary artery,…

Vascular access complications

Both femoral and radial access may lead to complications that are discussed in this chapter. 29.1 Femoral access complications Femoral access complications include lower extremity ischemia (due to dissection, embolization, or thrombosis), bleeding (groin hematoma and retroperitoneal hematoma), arteriovenous fistula, pseudoaneurysm, infection, and nerve injury. 29.1.1 Lower extremity ischemia 29.1.1.1 Diagnosis Lower extremity ischemia has various manifestations: Acute limb ischemia: manifests as the 6Ps (pain, pallor,…

Other complications: hypotension, radiation skin injury, contrast-induced acute kidney injury

In this chapter we discuss three non-coronary complications: hypotension, radiation skin injury, and contrast-induced acute kidney injury (CI-AKI). 28.1 Hypotension CTO Manual Online cases 69 , 85 , 92 , 129 , 146 PCI Manual Online cases 23 , 27 , 40 , 45 , 72 Continuous careful monitoring of the pressure and electrocardiographic tracing is critical for enhancing the safety of PCI ( Section 2.2…

Equipment loss and entrapment

Various types or equipment, such as stents, guidewires, and various catheters can be lost or entrapped either within or outside the coronary artery . Such equipment can lead to occlusion or perforation of the coronary vessel. It could also lead to systemic embolization, such as embolization to an intracranial artery causing a stroke. Device entrapment is a more grave complication than device loss, and may require…

Acute vessel closure

CTO PCI Manual Online cases: 38 , 92 , 98 , 112 , 125 PCI Manual Online cases: 18 , 21 , 40 , 44 , 57 , 68 , 72 , 81 Acute vessel closure is defined as (partial or complete) decrease in antegrade coronary flow that occurs during or immediately after percutaneous coronary intervention. Fig. 25.1 outlines a step-by-step algorithm for approaching such lesions.…

Complex patient subgroups

Complex patient subgroups that will be discussed in this chapter include: TAVR patients Cardiogenic shock patients 24.1 TAVR patients CTO Manual Online case: 113 PCI Manual Online case: 62 Transcatheter aortic valve replacement (TAVR) is increasingly being performed for symptomatic aortic stenosis patients, even those at low surgical risk. Coronary angiography and percutaneous coronary intervention (PCI) is often required in TAVR patients and carries unique challenges,…

Other complex lesions

In addition to calcification, thrombus, and CTOs, other complex lesion types include: Spontaneous coronary artery dissection (SCAD) (PCI Manual Online case 72 ), Stent failure (in-stent restenosis and stent thrombosis), CTO Manual Online cases: 19 , 52 , 54 , 58 , 72 , 84 , 91 , 101 ; PCI Manual Online cases: 63 , 89 , 94 Small and large vessels, and Long lesions.…

Chronic total occlusions

Chronic total occlusions (CTOs) are defined as completely occluded coronary arteries with Thrombolysis In Myocardial Infarction (TIMI) 0 flow with an estimated duration of at least 3 months . CTOs can be challenging to recanalize, requiring specialized equipment and techniques , which is covered in detail in the Manual of Chronic Total Occlusion Interventions . A global consensus document on the key principles underlying CTO PCI…