Innovative technique to achieve hemostasis with large bore access for percutaneous hemodynamic support devices

Background: The TandemHeart(TH) is a left atrial-to-femoral artery (LA-FA) percutaneous left ventricular assist device (pLVAD) used for hemodynamic supportduring high risk percutaneous coronary intervention (PCI). TH requires large bore venous and arterial sheaths, for which access site complications and management pose a significant challenge. We report a unique method of achieving vascular hemostasisand outcomes after removal of the TH post PCI. Methods: 14 LA-FA THs were placed from September 2015 to October 2016 at Henry Ford Hospital. 9 patients received TH support during complex PCI. Hemodynamic and clinical data, including accessmanagement were collected and analyzed. Results: 9 THs were placed to assist with complex PCI. Mean age and EF was 68.77 ± 16.1 and 29.8% ± 22.6%, respectively. Procedural success and vascular hemostasis was achieved in 100% of patients, with100% 30 day survival. TH was removed immediately after the PCI in all patients. Venous sheaths for all cases were 21Fr in size. Arterial sheaths were 17Fr for 78% of patients and 15Fr for 22% of patients. Venous closure was achieved utilizing manual compression in 23% of patients and pre-closure witha suture mediated vascular closure device (VCD) in 77% of patients. Arterial hemostasis was achieved using pre-closure with a Perclose VCD in conjunction with an 8Fr Angio-Seal, where a 0.035” wire was introduced through the arterial cannula by puncturing through the cannula wall and was used to deploy an 8 Fr. AngioSeal device before final cinching of the Perclose VCD sutures. Ipsilateral proximal artery balloon tamponade was additionally used in in 45% of patients with an average tamponade time 67.5 seconds. Heparin was used in 89% patients Bivalirudin in 11% with an average peak ACT of 366.7 seconds. Mean duration of TH supportwas 165.25 ± 130 minutes. Hematuria requiring transfusion occurred in 1 patient and minor vascular complication (hematoma) occurred in 1 patient. Conclusions: Percutaneous closure of large borevascular access required of the TH pLVAD is safe and provides successful hemostasis by instituting an innovative combination of 8 Fr. Angio-Seal in addition to pre-closure with Perclose VCD devices

TCT-288 Trends and Outcomes of Utilization of Thrombectomy During Primary Percutaneous Coronary Intervention

Background: The aim of this study was to describe the national trends and outcomes of contemporary thrombectomy use for primary percutaneous coronary intervention (PCI) from 2016 to 2018. Methods: We queried the Nationwide Readmission Database from January 2016 to December 2018 to identify patients who underwent primary PCI and thrombectomy. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality and stroke in patients undergoing primary PCI and those who underwent thrombectomy. Results: We identified 409,910 total hospitalizations who underwent primary PCI (Figure 1). Thrombectomy was used in 62,446 records (15.2%) with no change in the trend over the study period (P trend = 0.52). Thrombectomy was used more in patients who had more cardiogenic shock and use of mechanical circulatory devices. The overall incidences of in-hospital mortality and stroke were 5.6% and 1.1%, respectively. The incidences of in-hospital mortality (6.7% vs 5.4%, P \u3c 0.001) and strokes (1.3% vs 1.0%, P \u3c 0.001) were higher in the thrombectomy group. On multivariable regression analysis adjusting for high-risk features, thrombectomy was not independently associated with in-hospital mortality (odds ratio [OR]: 1.04; 95% confidence interval [CI]: 0.99-1.08, P = 0.100) but was associated with a higher risk of stroke (OR: 1.186; 95% CI: 1.097-1.283, P \u3c 0.001). Conclusion: During primary PCI, thrombectomy was used in 1 of 6 cases, and its use has been stable over 2016 to 2018. The use of thrombectomy was associated with a higher risk of stroke but not in-hospital death

Hemodynamics of High-Risk Percutaneous Coronary Intervention With and Without Mechanical Circulatory Support: A Pilot Study With Pressure Volume Loop Analysis

Background: Changes in left ventricular (LV) contractility during high-risk percutaneous coronary intervention (HR-PCI) may foretell hemodynamic collapse that could be prevented by timely use of mechanical circulatory support (MCS). The purpose of this pilot study was to assess the feasibility and sensitivity of pressure volume loop (PVL) analysis to characterize changes in LV contractility and loading conditions during HR-PCI performed with and without Impella MCS (Abiomed; Danvers, Massachusetts). Methods: Nine patients underwent HR-PCI, 6 with Impella MCS. LV pressures and volumes were measured with a conductance catheter at key time points during the case. PVL were analyzed to detect changes in LV contractility and loading conditions. Results: Impella support resulted in changes in PVL shape (rectangular → triangular) related to the loss of isovolumic periods (Figure A). Increasing Impella speed setting resulted in a large degree of LV unloading (progressive decreases in LV volume) (Figure B). In some cases, balloon inflation resulted in decreased contractility that was not detectible from changes in blood pressure and that recovered on balloon deflation (Figures C and D). [Figure presented] Conclusion: PVL analysis was feasible during HR-PCI, including during Impella support. Alterations in LV contractility and load were detected in real time before changes in routinely measured vital signs were apparent. Future investigation will focus on whether PVL analysis can help risk stratify HR-PCI patients and determine conditions under which MCS minimizes post-procedural decreases in LV contractility

Feasibility and Safety of Orbital Atherectomy for the Treatment of In-Stent Restenosis

Background: Debulking and ablative techniques are used for the treatment of in-stent restenosis (ISR). The safety and efficacy of orbital atherectomy (OA) in this cohort of patients has not been reported. Methods: We retrospectively evaluated procedural as well as clinical outcomes in patients treated with OA for ISR secondary to underlying calcific disease at two academic tertiary care centers from Oct 2016 to Sept 2018. Results: A total of 38 patients underwent OA for ISR during the period with mean age 66 +/- 12 yrs; 74% male, 63% diabetic, 39% post-CABG and 61% with a prior incident of ISR. Patients presented with NSTEMI (32%), unstable angina (18%) and stable angina (50%). Implantation of culprit stent occurred between 4 months to 22 years prior to the index procedure. The severity of ISR according to the Mehran classification; type 1 (24%), 2 (26%), 3 (18%) and 4 (32%). Angioplasty prior to OA was performed in 45% of cases and post OA in 95% of cases. Intracoronary imaging was performed in 79% of cases. There was one (3%) periprocedural MI from no reflow phenomenon. There was one (3%) Ellis type II coronary perforation thought to be related to aggressive post OA angioplasty that resulted in no measurable clinical sequelae. There were no reports of equipment malfunction or harmful device/stent interactions. Conclusion: OA can be safely performed as an adjunctive tool in the treatment of ISR. Caution must be taken in these high risk lesions to limit complications and harmful device/stent interactions

FIGURE 7 in Four new species of Australian velvet ants (Hymenoptera: Mutillidae, Aglaotilla) reared from bee and wasp nests, with a review of Australian mutillid host records

FIGURE 7. Aglaotilla micra sp. nov., ♀, holotype. A: facial view; B: lateral view; C: mesosoma, dorsal view; D: metasoma, dorsal view