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Lemor A, Basir MB, Patel K, et. al. on behalf of the National Cardiogenic Shock Initiative Investigators. J Am Coll Cardiol Intv 2020;13:1171–8
Potential advantages of complete revascularization vs. culprit only PCI in the setting of cardiogenic shock remains controversial in the US. To address this question, data from the National Cardiogenic Shock Initiative (NCSI), a multicenter registry of patients undergoing early MCS (Impella) in the setting of acute myocardial infarction with cardiogenic shock (AMICS). The key features of the suggested protocol include Impella unloading prior to PCI revascularization of the culprit lesion focusing on invasive hemodynamic management. This review encompasses patients with multivessel disease who underwent culprit only or multivessel PCI at the index procedure based on operator decision.
- The retrospective analysis included 198 patients with multivessel (MV) coronary artery disease (CAD).
- 126 (64%) had MV PCI; 72 (36%) had culprit only PCI.
- Baseline characteristics of both groups were similar including age, sex, diabetes, prior PCI or CABG.
- Patients undergoing MV PCI had a non-significant trend to worse cardiac output and lactate levels up to 12 hours.
- By 24 hours post PCI, there were similar hemodynamic responses.
- Survival rates were similar; MV-PCI (69.8%) while culprit PCI 65.3%, p = 0.51.
- Acute kidney injury was not significantly different – MV-PCI 29.9% vs. culprit only PCI 34.2%; p = 0.64.
- Similar outcomes for patients undergoing MV- PCI suggests that in selected patients, MC PCI in patients with early unloading is an acceptable approach.
A COVID -19 Perspective
- Given the need to minimize ICU beds in the event of a COVID – 19 escalation and to minimize patient (and Staff) risk, minimizing hospital days is favorable.
- Thus, in appropriate AMICS patients, use of an NCSI type protocol with MV-PCI, hospitalization ideally can be reduced with a 70% expected survival.
George W. Vetrovec, MD, MACC. Poll Results: COVID-19 Hypercoagulable Complications – American College of Cardiology
Lax SF, Skok K, Zechner P, et al. Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome: Results From a Prospective, Single- Center, Clinicopathologic Case Series. Ann Intern Med 2020;May 14:[Epub ahead of print].
Paranjpe I, Fuster V, Lala A, et al. Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19. J Am Coll Cardiol 2020;May 5:[Epub ahead of print].
Background: In a recent Poll on ACC.org. the questions related to coagulation abnormalities in COVID – 19 patients. As noted, most respondents use anticoagulation in COVID – 19 patients. In order of risk pulmonary emboli was the highest including both in-situ and traditional embolic events.
- Baseline coagulation profiles are often abnormal.
- Thrombotic events appear common
- Pulmonary emboli appear most common.
- Prophylactic anticoagulants may reduce the risk of thrombotic events.
- Paranjpe et al. reported significantly reduced mortality for ventilated patients with COVID-19 on anticoagulants (29.1%) versus 62.7% for those not receiving anticoagulation.
- Individualized decisions are important to minimize bleeding complications
SCAI Position Statement on Optimal Percutaneous Coronary Interventional Therapy for Complex Coronary Artery Disease
Riley RF, et. al. for the Writing Group. Catheter Cardiovasc Interv. Published online. doi: 10.1002/ccd.28994.
This document is meant to discuss the approach to the high-risk PCI procedure defined by anatomic and patient features. The document is extensive and thus this commentary seeks to increase the awareness of some of the benefits and procedure related requirements within this topic which warrant consideration in the framework of achieving optimal PCI outcomes.
- Pre-Procedural Assessment:
- Coronary Anatomic Complexity – May require advanced techniques
- Higher-risk clinical features
- Emphasis on importance on multivessel disease
- Procedure risk
- Recognize high risk of surgical turndowns
- Reduced left ventricular (LV) function
- Acute Coronary Syndrome – Left Main (LM) and Low LVEF
- Emphasized the importance of mechanical Support (MCS)
- Most common is pVAD type of axial pump
- MCS support shown to increase frequency of complete revascularization
- Selected cases MCS supports improved LV function
- Managing the risk of acute kidney injury
- Concomitant valve disease
- Treatment of complex coronary artery disease
- Arterial access
- Anticoagulation and antiplanet treatment
- Intracoronary physiologic testing and imaging
- Special lesion considerations – LM, Bifurcations, Vein Grafts, In-stent Restenosis and Chronic Total Occlusions.
- The authors conclude: “…this SCAI consensus document provides an initial platform to offer guidance for achieving excellent outcomes for complex PCI and to support future investigations of this growing patient population.
Editorial Comment: This document provides an important roadmap for providing optimal outcomes for PCI in patients with complex coronary artery disease – Its more than “getting out of the lab”! it’s about getting optimal acute and late results. In the current era of COVID, certain of these recommendations become particularly important in attempting to reduce hospitalVIEW