2022 Scientific Sessions

Title

Percutaneous left ventricular assist device saving the day: Successful use of PulseCath iVAC 2L in high-risk PCI patient

Introduction

Coronary artery bypass grafting is generally preferred in symptomatic patients with severe, complex multivessel, and/or left main disease. However, for patients who decline surgery or are declined by the surgeon due to their comorbidities or clinical characteristics percutaneous intervention may be the only feasible treatment. For patients with more high-risk characteristics using mechanical circulatory support devices is standard practice despite lack of strong evidence. As Impella might be unavailable or unaffordable in some centres and intra-aortic balloon pump offer limited haemodynamic support there is a need for affordable and effective mechanical circulatory support device to use in high-risk PCIs. We present a case of successful use of PulseCath iVAC 2L device during LM intervention in a very high-risk patient who declined surgery.

Clinical Case

64-year-old patient was admitted due to 2 weeks of exertional angina and dyspnoea. His past medical history included type 2 diabetes, arterial hypertension, and atrial fibrillation. On ECG there was left bundle branch block. In laboratory results the troponin was negative and BNP was elevated - 309 pg/ml (normal less than 100). Echo showed severely reduced left ventricular ejection fraction (25%) with segmental wall motion abnormalities predominantly of the septal, lateral and inferior segments. The working diagnosis was ischemic cardiomyopathy and coronary angiography was performed. We could see calcified coronary arteries with 80-90% stenosis of LM, significant stenosis of the ostioproximal and mid-LAD, distal occlusion of LCX with left-to-left collaterals and diffusely diseased RCA. Surgical treatment was suggested to patient but he declined it. Hence, we offered him percutaneous treatment with high risk. Due to many high-risk features (severely reduced EF, multivessel disease, unprotected LM intervention) we opted for elective mechanical circulatory support use. As intra-aortic balloon pump offers limited support and Impella is not available in our country we decided to use PulseCath iVAC 2L device which was implanted before PCI. While dilating the LM-LAD with the NC balloon, the donor vessel dissected and bradycardia followed by pulseless electrical activity. The PulseCath iVAC 2L enabled us to continue with the procedure without interrupting the procedure for manual chest compression. The lesion in LM was promptly stented, TIMI 3 flow was achieved and the return of spontaneous circulation was restored. PulseCath iVAC 2L device was removed immediately after the procedure and patient was soon discharged home free of chest pain and with medications for his heart failure.

Discussion

Our case of very high-risk ULM PCI resulted in a brief cardiac arrest during intervention. Due to preserved flow by the PulseCath iVAC 2L by setting it to asynchronous mode we did not need to interrupt the procedure and begin manual chest compressions. So the use of this device for high risk PCIs could be a promising alternative to limited support by intra-aortic balloon pump and limited availability of Impella.