High-Risk Percutaneous Coronary Intervention: Challenges and Considerations

Announcing a new article publication for Cardiovascular Innovations and Applications journal.

As global life expectancy increases, cardiologists increasingly face challenges of caring for an older population requiring complex coronary revascularization. A substantial portion of these patients are deemed unsuitable for surgery because of their comorbidities, coronary lesion characteristics, and hemodynamic status. In response to the therapeutic needs of this patient cohort, innovative devices and techniques have been developed to provide viable options for treatment. In assessing these patients, the heart team approach is critical, to identify anatomic, hemodynamic, and procedural characteristics that favor adjunctive MCS support. The available data support using adjunct MCS devices in patients with severely reduced LV function (EF < 35%) or in acute decompensated heart failure in the presence of complex coronary artery disease.

Given the considerable morbidity and mortality risks in patients undergoing high-risk and complex PCI, thorough clinical and invasive hemodynamic assessments are essential before MCS devices are selected, and revascularization is performed. The choice of MCS device depends on multiple factors, including patient anatomy, device availability, local operator expertise, the required amount of hemodynamic support, and technical characteristics such as ease of deployment and removal. Currently, the most widely used device is an IABP, which is followed by Impella, TandemHeart, and VA-ECMO. Generally, more severe clinical and anatomic circumstances are associated with greater potential benefits of MCS use. The timing of insertion remains controversial, but sufficient observational data support a recommendation of initiating MCS support before the commencement of PCI; in most cases, MCS devices can be removed immediately after the intervention. Continuous hemodynamic monitoring with a pulmonary arterial catheter is encouraged at the earliest opportunity to tailor therapy, and to assist in determining the amount and duration of MCS support needed.

Additional research is needed to understand the patient and device characteristics associated with technical and clinical success after HRPCI. Moreover, MCS devices, with their various advantages and disadvantages, must be directly compared to establish which devices optimize patient outcomes. These devices should not be considered the standard of care for every complex procedure; instead, the use of MCS devices should be individualized to selective patients after a comprehensive review of their risks and benefits through a heart-team approach.

https://www.scienceopen.com/hosted-document?doi=10.15212/CVIA.2024.0029

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Venkata Sai Gogineni and Khanjan B. Shah. High-Risk Percutaneous Coronary Intervention: Challenges and Considerations. CVIA. 2024. Vol. 9(1). DOI: 10.15212/CVIA.2024.0029