Advances in Hemodynamics: Meeting Encourages Conversation About Best Practices
MIAMI BEACH, FL—As percutaneous coronary intervention (PCI) continues to evolve and expand, physicians must increasingly employ various methods of hemodynamic support to optimize results in high-risk patients. However, as discussed at the recent Advances in Hemodynamics meeting held January 23-24, 2014, lacking a precise definition of ‘high-risk’ and facing a wide variety of device options, physicians and institutions often perform procedures inconsistently and with few options for hemodynamic support. These currently include intra-aortic balloon pumps (IABPs), percutaneous left ventricular assist devices (LVADs; TandemHeart; CardiacAssist, Pittsburgh, PA and Impella; Abiomed, Danvers, MA), and extracorporeal membrane oxygenation (ECMO).
While 1 prior study has shown IABP use to be associated with a higher risk of bleeding and mortality when used in urgent vs elective cases, another study showed no advantage in mortality for IABP use in high-risk PCI regardless of the level of institutional utilization. With regard to the Impella device, the PROTECT II trial, published online August 2012 in Circulation, showed no improvement in 30-day outcomes compared with IABP support in high-risk PCI.
Case Discussions Start the Day
In the first meeting to focus exclusively on hemodynamic support, the Cardiovascular Research Foundation (CRF) brought together 76 physicians from the United States and Canada to discuss these issues at the Advances in Hemodynamics symposium. Chaired by Jeffrey W. Moses, MD, and Ajay J. Kirtane, MD, SM, both of NewYork-Presbyterian Hospital/Columbia University Medical Center (New York, NY), and John M. Lasala, MD, PhD, of Washington University School of Medicine (St. Louis, MO), the meeting aimed to educate clinicians and improve their ability to manage patients.
The program began with participants splitting into 10 groups to discuss case presentations submitted by attendees. Questions and comments during this session focused on how to determine when a patient is high risk, the proper timing for device deployment, and the need for more evidence-based theories and practices. Three of the presentations were selected by the chairs to be presented in full the following day:
- Henry Cusnir, MD, of Florida Medical Center (Fort Lauderdale, FL): 67 year old female presenting with AMI and critical LM disease who had multiple in-hospital cardiac arrests was implanted with an IABP, turned down by surgery, and eventually underwent a successful multi-stent interventional procedure on IABP
- Samir Pancholy, MD, The Wright Center for Graduate Medical Education (Scranton, PA): 62 year old male with STEMI treated with Impella support for 2 days after unsuccessful IABP treatment
- Rajan Patel, MD, of Ochsner Medical Center (New Orleans, LA), presented a 74-year-old man with cardiogenic shock and unprotected left main disease who was treated with multivessel PCI and Impella CP
In a telephone interview with TCTMD, Dr. Kirtane said the session “allowed us to identify those types of real-life questions that come up in daily practice and vary from site to site and region to region. For me, that was a unique experience and really allowed everybody at each table to share in others’ experiences and figure out how others do things differently.”
Discussion Shifts Preference to Impella
The program was heavily reliant on audience participation, especially live polling. At the beginning of the day, attendees were asked about institutional preferences. Nearly half of respondents said they had access to IABPs plus percutaneous LVADs, while 29.4% had those options plus additional access to ECMO, 20.6% had IABPs alone, and 2.9% had only IABPs and ECMO. Two-thirds of respondents did not feel like they had enough device selection at their disposal, and the majority (75%) cited IABP as the default device used at their institution. While most attendees (69.7%) said they feel no institutional pressure regarding hemodynamic support, the remainder were evenly split as to whether they felt pressured to do more (15.2%) or pressured to perform less (15.2%).
As for case selection, more than half of respondents (54.5%) said they would strongly consider prophylactic hemodynamic support when there is a high likelihood of complete hemodynamic collapse. Two-thirds (66.7%) strongly preferred to use the Impella 2.5 device; while the remainder preferred IABPs (23.8%), Impella LP (4.8%), and ECMO (4.8%); none preferred the TandemHeart device. Most respondents (65.2%) said they use support to “avoid catastrophe,” while the rest use it to “allow for more aggressive and intensive treatment” (26.1%) or to “make the case smoother” (8.7%).
In high-risk cases, respondents varied on their preferred treatment option:
- Sequential, staged ischemia guided PCI after “culprit” treatment: 42.9%
- Fix culprit and finish procedure: 23.8%
- Symptom driven after culprit: 19.0%
- “Complete revascularization” at that sitting: 14.3%
In patients with cardiogenic shock, most respondents (85%) agreed that the interventional cardiologist should typically be the one most responsible for deciding what type of hemodynamic support to use, 10% said the decision should be made by the heart failure specialist, and 5% decided by the cardiac surgeon. Participants were also in general agreement as to how shock patients should be managed; 76.5% said support should be used upfront prior to revascularization while 23.5% said to revascularize first and decide upon support at the end of the case.
More specifically, attendees said their ideal philosophy in choosing a support option for patients with cardiogenic shock was:
- Use potent (non-IABP) support early and bypass use of IABP for most cases: 57.9%
- Use IABP first and transition to more potent support for patients failing IABP: 31.6%
- Use nothing upfront and reserve support for patients who fail conventional medical therapy: 10.5%
In a final poll conducted at the end of the day, the vast majority of respondents said the meeting changed their inclination for the use of active support in cardiogenic shock (92.7%) and high-risk PCI (80.8%). Going forward, 84.6% of attendees said they would prefer using the Impella device, while the remainder stuck by the ECMO via a standard bypass circuit (3.8%) or some other system (7.7%), or preferred TandemHeart (3.8%).
Training Key to Moving Forward
“In some respects, we feel that hemodynamics have become somewhat of a lost art. There’s recognition now that hemodynamics are very important,” Dr. Kirtane said. “They are important not only in terms of symptoms but also in terms of prognosis, and when you do cases in patients that are at high risk, those hemodynamics and the attention to them can really be the difference between doing a procedure safely and successfully and not.”
With more and more patients presenting with complex and refractory disease, “it’s important for interventionalists who are going to be confronted by these patients to understand how to treat them safely and effectively,” he continued. “In order to do that, we have to train folks to be able recognize these types of cases and then how to manage them.”
Note: Advances in Hemodynamics was sponsored by the Cardiovascular Research Foundation, which owns and operates TCTMD.
Advances in Hemodynamics; January 23-24, 2014; Miami Beach, FL.
- The meeting was supported by a grant from Abiomed.
- Dr. Kirtane reports that his institution receives research support from Abbott Vascular, Abiomed, Boston Scientific, Medtronic, and St. Jude Medical.