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228 PART IV Wires Technique
Intravenous
•
hydration
(tailored to
patient’s volume
status)
Potent statins
•
Stop nephrotoxic
•
drugs
IVUS
•
Dextran-based OCT
•
FFR/iFR
•
Pre-procedural
Interventions
Coronary
Imaging and
Phsiology
Device-based
Interventions
Other
Strategies
•
DyeVert PLUS
•
Renal Guard
•
Impella
Contrast-sparing
•
strategies
(see Tablet 1)
•
Coronary sinus
aspiration
•
Remote ischemic
condtioning
•
Radial access
Iso- vs. low-
•
osmolar contrast
media
Figure 24.6 Procedural strategies to reduce the incidence of contrast-induced acute kidney injury during percutaneous
coronary intervention. Almendarez M, Gurm HS, Mariani J Jr, et al. Reproduced with permission from Almendarez et.al.,
© 2019, Elsevier.
especially since these patients already have an indica-
6 Tsai TT, Stanislawski MA, Shunk KA et al. Contemporary
tion for the initiation and maintenance therapy with
high dose statin treatment. Zero contrast PCI, intravascular ultrasound-guided and physiology-guided
PCI or the use of the Impella devices for the prevention of CA-AKI are valuable options that are currently
assessed, and a final determination has not been made.
Therefore, they can be used in selected cases, but probably will not be used routinely in every case.
References
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25
CHAPTER 25
Mechanical Support for CTO
Khaldoon Alaswad1,*, Asaad Nakhle1 , Ankur Gupta2,
Katherine J. Kunkel3 & Mir Babar Basir
1
Henry Ford Hospital, Detroit, MI, USA
2
Piedmont Heart Institute, Atlanta, GA, USA
3
HonorHealth Scottsdale Shea Medical Center, Scottsdale, AZ, USA
* Corresponding author
1
Introduction
Mechanical circulatory support (MCS) is used in
approximately 5% of coronary chronic total occlusion percutaneous coronary interventions (CTO PCI).
While MCS is used sparingly in CTO PCI, selective use
can facilitate successful revascularization in a particularly high-risk and often underserved patient group.
MCS use during CTO PCI (supported CTO PCI)
is generally related to patient factors (low hemodynamic reserve, advanced age, or other comorbidities)
or technical factors related to CTO PCI technique (last
remaining conduit, retrograde techniques) that increase
the risk of hemodynamic collapse during the procedure
[1]. This chapter will describe which patients are most
likely to require supported CTO PCI, the physiology of
hemodynamic support devices, factors to consider in
device selection, and technical aspects of the use of various mechanical circulatory support devices.
Defining the risk of hemodynamic
collapse during CTO PCI
The use of mechanical circulatory support devices has
been studied in the context of cardiogenic shock [2–5]
and high risk coronary interventions [6, 7]. There is a
paucity of data on the use of MCS in CTO PCI with no
published prospective studies of supported CTO PCI
to date. Available data describing supported CTO PCI
is observational and largely derived from registries of
CTO PCI. As a result, the consensus on the use of
MCS during CTO PCI is based on the experience of
high-volume expert operators [8].
CTO PCI is a special case of complex and high risk
PCI that may require MCS in selected patients. Following
a similar paradigm as high risk PCI in general, three
main factors contribute to the risk of intra-procedural
hemodynamic collapse and the need for MCS during
CTO PCI: patient-specific comorbidities, hemodynamic
factors, and procedural factors (Figure 25.1).
Prospective registry studies have identified advanced
patient age, frailty, prior heart failure, chronic respiratory
insufficiency, renal insufficiency, and peripheral arterial
disease as patient-specific comorbidities associated with
worse outcomes in CTO PCI [1]. Similarly, reduced LVEF
is associated with increased risk during CTO PCI because
it decreases the myocardial reserve during the procedure.
As a result, reduced LVEF has been used as inclusion criteria to study the use of MCS in high risk PCI in both
the PROTECT II and BCIS-I trials. [6, 9] Additionally,
comorbid valvular lesions such as mitral regurgitation or
aortic stenosis increase the risk of high risk PCI due to
reductions in cardiac reserve and hemodynamic derangements. Together, these factors determine the likelihood of
tolerance to ischemia, arrhythmias, prolonged sedation,
or procedure time, or potential complications during
CTO PCI, all of which increase the risk of hemodynamic
deterioration during the CTO PCI.
In addition to increasing the risk of hemodynamic collapse during CTO PCI, valvular heart disease also poses
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
232
CHAPTER 25 Mechanical Support for CTO 233
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Patient
Age>75years
DepressedLVEF
Left-sidedAdvancedValvular Heart Disease
UnstableRhythmDisturbances
AcuteCoronarySyndrome
DecompensatedHeartFailure
Renalfailure
Useofdominantepicardialcollateral
Retrogradetechniquethroughthelast
availableconduitortheLIMAtoLAD
Multivesselinterventions
Hemodynamics
SBP<100mmHg
↑PCWPorLVEDP>20mmHg
CardiacIndex<2.2L/m
CardiacPowerOutput<0.6
elevated CVP
2
Procedure
Figure 25.1 Risk categories to predict hemodynamic compromise during CTO PCI. CVP, Central Venous Pressure; LVEF, Left
Ventricular Ejection Fraction; PCWP, Pulmonary Capillary Wedge Pressure; SBP, Systolic Blood Pressure.
technical considerations in the choice of mechanical
circulatory support device. Intra-Aortic Balloon Pump
(IABP) is contraindicated in patients with moderate or
severe aortic regurgitation (AR). Severe aortic stenosis
and moderate or severe aortic regurgitation precludes
the use of coaxial micropumps such as the Impella
device (Abiomed, Danvers, MA, USA). Patients with
severe mitral regurgitation or stenosis may benefit from
devices that unload the left atrium directly such as the
TandemHeart (TandemLife, LivaNova, London, UK).
The second factor to consider in the use of MCS in
CTO PCI is the patient’s baseline hemodynamic status.
Although CTO PCI should not be performed in patients
with acute decompensated heart failure or shock, some
patients with severe ischemic cardiomyopathy may
never achieve complete hemodynamic optimization
before revascularization, particularly in those with
multivessel coronary artery disease. Right heart catheterization (RHC) should be performed before CTO PCI
in patients with other risk factors for hemodynamic
collapse (Figure 25.1). It is vital to measure filling pressures, pulmonary artery pressures, pulmonary artery
oxygen saturation, cardiac output (CO), systemic blood
pressure, and right ventricular hemodynamic indices
such as the pulmonary artery pulsatility index (PaPi)
to make informed decisions about the need for MCS
and the device that is most appropriate during specific
CTO PCI procedures. Baseline hemodynamic values
can also be helpful in evaluating the impact of the
procedure on the patient’s hemodynamic status as well
as the need for post-procedure continued mechanical
circulatory support. Patients with high filling pressures
and/or low CO are at the highest risk of hemodynamic
compromise in the event of periprocedural ischemia
resulting in myocardial stunning of large myocardial
territory and thus are generally the patient most likely
to require supported CTO PCI [10]. Additionally,
information from continuous PA catheter monitoring
during the CTO procedure may assist in periprocedural clinical decision making regarding the ongoing
use of MCS, escalation of MCS, or the decision to stop
the procedure [11]. Rising intra-procedural pulmonary
artery pressures and/or progressive reduction in the
PAO2 saturations are important indicators of impending hemodynamic compromise and provide critical
information to the operator throughout the procedure.
The third factor to consider in weighing the indication
for MCS in CTO PCI is the specific technical strategies
planned for the procedure and their associated potential complications. Collateral crossing during retrograde CTO PCI or side branch occlusion after dissection
and reentry might cause myocardial stunning in large
myocardial territory leading to hemodynamic collapse
[12, 13]. Successful revascularization of a CTO does not
lead to immediate recovery in the myocardial function
which makes any additional myocardial stunning in
234 PART IV Wires Technique
Figure 25.2 Prominent epicardial collateral from left circumflex to right coronary artery. Arrow head: large collateral vessel.
other territories less tolerated by the patient. In patients
with poor hemodynamic reserve, antegrade strategies are
preferred to avoid donor vessel and collateral ischemia.
Retrograde crossing, particularly via prominent tortuous
collaterals (Figure 25.2), may induce profound ischemia.
Additionally, crossing the last patent conduit to access
collaterals during retrograde procedure puts the patient
at high risk of hemodynamic collapse, particularly if
there is disease in the donor vessel or in the event of a
donor vessel complication such as a flow limiting dissection or thrombosis. For example, dissection in the left
internal mammary artery graft (LIMA) to the left anterior descending artery (LAD) during collaterals crossing
LVEF<50%:Evaluate
LVEF<40%:RecommendRHCpriorto
+2CardiacIndex<2.0orPAsat<55%
+1Syntaxscore
+1LVEF<25%
+1SBP<100 mm Hgatbaseline
+1ACSpresentation
+1PlannedRevascularization
territories
+1LikelyProlongedIschemia
•RetrogradeCTO
•Atherectomy
+1Severemitralregurgitation
+1Decompensatedstate
•LVEDP>20
• Significantneworthopnea
-1Highriskvascularinjury/significant
bleeding
-1Hemoglobin<8 mg/dl
22
through the LIMA would likely result in hemodynamic
collapse, even if the non-target vessel were patent.
When considering the patient risk factors, hemodynamic status, and technical risk factors in determining
the need for MCS in CTO PCI, it is important to consider the totality of risk. The more factors a given
patient has, the higher the likelihood of hemodynamic
collapse and, thus, the need for consideration of MCS.
This concept is illustrated in a proposed protected PCI
algorithm (Figure 25.3) which, although developed for
any complex high-risk PCI, is very relevant to the CTO
PCI [14]. This algorithm includes various factors that
increase the risk of hemodynamic collapse and assign
Unlikelyto
NeedSupport
0
3
2
Consider
Support
Strongly
Consider
Support
Figure 25.3 Protected PCI algorithm. Adapted from Davies et.al., 2021. Abbreviations similar to Figure 25.1. ACS, Acute
Coronary Syndrome; CTO, Chronic Total Occlusion; LVEDP, Left Ventricular End Diastolic Pressure.
CHAPTER 25 Mechanical Support for CTO 235
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them relative weights. The collective effects of multiple
factors are more important than any individual factor.
The potential hemodynamic benefits of MCS in
CTO PCI must be weighed against the
potential
complications associated with the use of MCS. This
includes complications related to large bore arterial
access which comes with an increased risk of bleeding,
access site complications, and distal limb ischemic [15].
Hemodynamic effects of MCS during
CTO PCI
The hemodynamic effects of MCS are device
dependent (Table 25.1). The goal of an MCS device
is to reduce demand-supply mismatch by increasing
myocardial perfusion and reducing myocardial oxygen
consumption while maintaining systemic perfusion.
By maintaining systemic perfusion and preventing
the development of cardiogenic shock and end-organ
damage, MCS devices enable the increased procedural
time and techniques used in CTO PCI to facilitate high
technical and procedural success rates [16].
It is important to consider the right ventricular
function when selecting an MCS device. Left ventricular (LV) support with coaxial LV pumps can unmask
right ventricular (RV) dysfunction which can result in
hemodynamic deterioration or underperformance/
malfunction of the MCS device. Devices that unload
the RV directly or indirectly should be considered in
patients with significant RV dysfunction [17].
Several hemodynamic parameters are increasingly
used to determine the need for MCS, decide which
MCS device to use, and monitor the effectiveness of
the MCS device. Cardiac power output (CPO) is calculated by multiplying the mean systemic pressure by
the cardiac output and then dividing by 451. The CPO
combines flow and pressure in one number to reflect
the patient’s overall hemodynamic status. A CPO of
less than 0.6 Joules in patients with cardiogenic shock
is associated with increased mortality [11, 18]. Another
useful parameter to consider is the cardiac output deficit
(COD) which is calculated by subtracting the measured
CO from a normal CO (normal cardiac output being
defined as 2.2
L/min/m
2
multiplied by the patient’s body
surface area). Each MCS provides a range of added flow
that can be matched to the COD to select the appropriate MCS device. The COD has not been previously
validated to guide the use of MCS devices.
Based on differing mechanisms of action, the various
commercially available MCS devices achieve different
levels of support and have different hemodynamic effects
[19]. The IABP uses intra-aortic counter pulsation by
inflating a balloon in the descending aorta during diastole
and deflating during systole. The net effect of the IABP
is a modest reduction in the LV afterload, an increase in
CO, and improved myocardial perfusion during diastole
in coronary arteries without significant stenosis [20, 21].
Coaxial micropumps use a magnetically or driveshaft
controlled rotor to unload the left ventricle by pumping
blood directly from the LV into the aorta. The hemodynamic effects of the coaxial micropumps include a
reduction in the left ventricular diastolic pressure, a
reduction in native LV stroke volume and workload, and
maintenance of adequate systemic perfusion. As a result
of these hemodynamic effects, the coaxial micropump
results in a significant decrease in myocardial oxygen
demand as well as an improvement in coronary perfusion pressure and blood flow, (Figure 25.4). The flow
through a coaxial micropump is dependent on the size
of the cannula and rotor as well as the speed of the rotation. The most commonly used microaxial pump is the
Impella CP which provides up to 3.5 – 4 L/min of flow.
When additional flow is needed or in the event of
mitral valve pathology, the TandemHeart device can be
used. The TandemHeart drains the oxygenated blood
from the left atria (LA) and a centrifugal pump returns
the blood to the arterial system via a transfemoral arterial
cannula. The hemodynamic effect of TandemHeart
is a decrease in LV preload and stroke volume with a
concurrent increase in LV afterload. The net effect is
a reduction in LV work and oxygen consumption by
reducing the pressure-volume loop area while maintaining the systemic and coronary flow. The TandemHeart
flow varies according to the sizes of the inflow and outflow cannulas. The Tandemheart can provide up to
4 – 5 L/min, possibly replacing the native resting CO.
Venous arterial extra corporal membrane oxygenation (VA-ECMO) has been rarely used in supported
Table 25.1 Hemodynamic effects of different mechanical circulatory support devices.
IABP Impella CP Tandem Heart VA-ECMO
Maximum Flow (L/min) 0.5 3.5 4.5 5
MAP ⇑ ⇑ ⇑ ⇑
Cardiac Output ⇑ ⇑ ⇑ ⇑
Afterload ⇓ Variable ⇔ ⇑
LVEDP ⇓ ⇓ ⇓ ⇑ or ⇔
Left Ventricular Unloading Improves Improves Improves Worsens
Myocardial Oxygen Demand ⇓ ⇓ ⇓ ⇔
236 PART IV Wires Technique
22/68/86 mmHg
Upper Tracing
Impella CP at P2
LV
Ao
DCP
ECPP
DPP
Lower Tracing
Impella CP at P8
LV
Ao
DCP
ECPP
DPP
Figure 25.4 Effects of Impella on coronary perfusion in patients with critical coronary artery stenosis [21], A case example
of distal coronary pressure (as measured by the pressure wire), left ventricular (LV) end-diastolic pressure (as measured by
the pigtail catheter), and systemic blood pressure (as measured by the procedural guiding catheter) simultaneously
displayed at low and high level of support. Ao indicates aortic pressure systolic/diastolic/mean; DCP, distal coronary
pressure, systolic/diastolic/mean; DPP, diastolic perfusion pressure that is the diastolic aortic pressure subtracted by the
left ventricular end-diastolic pressure; and ECPP, effective coronary perfusion pressure that is the mean aortic pressure
substracted by the left ventricular end-diastolic pressure. Alqarqa et al., 2018 / American Heart Association, Inc.
116/12/21 mmHg
112/43/68 mmHg
72/19/35 mmHg
47 mmHg
22 mmHg
126/12/18 mmHg
1
81/20/41 mmHg
68 mmHg
50 mmHg
CTO PCI. The VA-ECMO decreases right ventricle
preload and increases LV afterload and work resulting
in increased cardiac oxygen demand. For this reason,
patients on VA-ECMO may benefit from LV venting
via a microaxial pump or left atria VA-ECMO configuration using a left atrial drainage cannula (Figures 25.5,
25.6) or a fenestrated LA cannula to drain the blood
from the left and right atria simultaneously (LAVA
ECMO). The LAVA ECMO provides excellent unloading of the right and left heart chambers. [22].
It is important to remember that except for IABP, the
native cardiac out is reduced by the use of most available
MCS devices, this leads to differences in CO improvement between the different devices’ configurations.
Patient selection
Because of the lack of validated algorithms to predict
hemodynamic collapse during CTO PCI, the operator’s
and center’s experience plays a major role in patient
selection for supported CTO PCI. Several common
themes have emerged from centers with advanced
experience in using MCS during CTO PCI (Figures
25.1, 25.3). MCS devices should be selected by weighing factors related to vascular access, degree of support
needed, and effects on the patients’ hemodynamics
and myocardial performance [23]. Advanced age is
considered a risk factor for procedure intolerance and
potential hemodynamic collapse, especially if associ-
Figure 25.5 Percutaneous access in LAVA ECMO with two separate drainage cannulas. Arrows: Venous drainage cannulas
from the left and right atriums Arrowhead: Arterial return cannula Asterix: Oxygenator.
CHAPTER 25 Mechanical Support for CTO 237
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Figure 25.6 LAVA ECMO configuration with two cannulas. Arrow: Left atrial drainage cannula through atrial trans-septal
access Arrowhead: Right atrial drainage cannula.
ated with depressed LV function, advanced valvular
disease, arrhythmias, acute coronary syndrome, or
decompensated heart failure. Despite low LVEF being a
key selection criterion in the two major trials of MCS in
high risk PCI, many patients without low LVEF require
MCS during CTO PCI, suggesting that the decision to
use MCS during CTO PCI is more nuanced and multifactorial than the patient’s ejection fraction alone.
Beyond the choice of device, the timing of the use
of mechanical circulatory support may be a significant
determinant in the patient’s outcome. Registries of
CTO PCI have shown that patients who received
MCS before the start of the CTO PCI have better outcomes when compared to patients who received the
MCS after the beginning of the CTO PCI procedure
[4, 8]. While these findings may be related to the
emergent use of MCS due to complications, one can
argue that the upfront use of MCS may have been
advantageous in the group of patients who require
MCS urgently due to technical considerations and
may have prevented as severe of hemodynamic compromise in the event of a complication. More investigation is needed to refine the models for predicting
which patients will require MCS given increased
vascular access site complications in emergent large
bore access. Accurate prediction model is more
important in patients with CTO because they tend to
have other high risk features for vascular access
complications.
The planned CTO PCI techniques or potential
complications of CTO PCI are also significant determinants of the need for MCS during CTO PCI. Using
the last remaining conduit to access the collaterals puts
the patient at increased risk of rapid hemodynamic
collapse. When retrograde gear results in significant
ischemia or in the event of a donor vessel dissection
or thrombosis, there is a large area of myocardium at
risk when the retrograde conduit is the last remaining
vessel. This can result in rapid hemodynamic collapse.
The risk of ischemia and myocardial stunning during retrograde crossing is also related to the number
of collaterals from the donor vessel to the occluded
vessel. If there are multiple sources of collaterals,
ischemia is less likely. If there is a single dominant collateral, the risk for hemodynamic compromise during
retrograde crossing is higher (Figure 25.2). Few cases
of CTO PCI procedures required MCS placement to
prevent malignant ventricular arrhythmia upon guide
engagement or collateral crossing.
Procedure examples
CTO PCI without MCS: A 46-year-old male survived
after 80 minutes of cardiopulmonary resuscitation for
pulseless electrical activity and ventricular tachycardia.
His hospital course was complicated by acute kidney
failure requiring hemodialysis. During his hospitalization, the patient was found to have distal abdominal aortic occlusion as well as coronary CTOs in the
proximal LAD and mid LCX. The diagonal branch and
two obtuse marginals were without significant stenosis.
Echocardiogram was notable for severely depressed LV
function (LVEF 17%), normal RV size and function,
and no significant valvular abnormalities. High risk
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