Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Summary

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Abstract

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Introduction

Cardiogenic shock (CS) is defined as persistent hypotension (systolic blood pressure <90 mmHg for >30 minutes, or the need for vasopressors or inotropes), end-organ hypo-perfusion (urine output <30 mL/h, cool extremities or lactate > 2 mmol/L), pulmonary congestion (pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg) and decrease cardiac performance (cardiac index <2.2 )^1,2 due to a primary cardiac disorder. Acute myocardial infarction (AMI) is th....

Protocol

This protocol is the standard of care in our institution.

1. Insertion of the PVAD (e.g., Impella CP)

1. Obtain common femoral access over the lower half of the femoral head under fluoroscopic and ultrasound guidance using a micro-puncture needle^9,10. Position the micro-puncture sheath and obtain an angiogram of the femoral artery to confirm appropriate arteriotomy location¹¹.
2. Insert a 6 Fr sh.......

Discussion

Minimizing the Risks and Complications of PVAD (Table 2)
The hemodynamic benefits of PVAD can be significantly neutralized if complications from large-bore access occur, such as major bleeding and acute limb ischemia^28,29. It is thus essential to minimize the risk and complications of the device.

In order to decrease access site complications and reduce the number of access attempts, ultrasound and fluoroscopic g.......

Materials

Name	Company	Catalog Number	Comments
4 Fr-018-10 cm Silhouette Stiffened Micropuncture Set	Cook	G48002	Microvascular access
5 Fr Infiniti Pigtail Catheter	Cordis	524-550S	pigtail catheter
Impella CP Intra-cardiac Assist Catheter	ABIOMED	0048-0003	Impella catheter kit