Elective or Emergency Use of Mechanical Circulatory Support Devices During Transcatheter Aortic Valve Replacement

• Published in: Journal of interventional cardiology Vol. 29; no. 5; pp. 513 - 522
• Main Authors: Singh, Vikas, Damluji, Abdulla A., Mendirichaga, Rodrigo, Alfonso, Carlos E., Martinez, Claudia A., Williams, Donald, Heldman, Alan W., de Marchena, Eduardo J., O'Neill, William W., Cohen, Mauricio G.
• Format: Journal Article
• Language: English
• Published: United States Blackwell Publishing Ltd 01.10.2016
• Subjects: Aged; Aged, 80 and over; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - surgery; Assisted Circulation - instrumentation; Assisted Circulation - methods; Assisted Circulation - mortality; Cardiopulmonary Bypass - instrumentation; Cardiopulmonary Bypass - methods; Cardiopulmonary Bypass - mortality; Elective Surgical Procedures - methods; Elective Surgical Procedures - statistics & numerical data; Emergency Medical Services - methods; Emergency Medical Services - statistics & numerical data; Female; Hospital Mortality; Humans; Male; Outcome and Process Assessment (Health Care); Prospective Studies; Severity of Illness Index; Survival Analysis; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - methods; United States - epidemiology
• ISSN: 0896-4327; 1540-8183
• DOI: 10.1111/joic.12323

Objective Evaluate the use of mechanical circulatory support (MCS) devices in high‐risk patients undergoing transcatheter aortic valve replacement (TAVR). Background The use of MCS devices in elderly patients with multiple comorbidities undergoing TAVR is underexplored. Methods All patients undergoing TAVR at a single tertiary academic center who required MCS during index procedure between 2008 and 2015 were included in a prospective database. Results MCS was used in 9.4% (54/577) of all TAVRs (n = 52 Edwards Sapien and n = 2 CoreValves) of which 68.5% (n = 37) were used as part of a planned strategy, and 31.5% (n = 17) were used in emergency “bail‐out” situations. IABP was the most commonly used device (87%) followed by Impella and ECMO (6% each). Among the MCS group, 22% required cardiopulmonary resuscitation during the procedure (n = 4 elective [11%] vs. n = 8 emergent [47%]) and 15% upgrade to a second device (Impella or CPB after IABP; n = 5 elective [14%] vs. n = 3 emergent [18%]). Median duration of support was 1‐day. Device related complications were low (4%). In‐hospital mortality in this extremely high‐risk population was 24% (13/54) (11% [4/37] for elective cases and 53% [9/17] for emergency cases). Cardiogenic shock (50%) was the most common cause of in‐hospital death. Cumulative all‐cause 1‐year mortality was 35% (19/54) (19% 97/370 for elective and 71% [12/17] for emergency cases). Conclusion Emergent use of MCS during TAVR in extremely high‐risk population is associated with high short and long‐term mortality rates. Early identification of patients at risk for hemodynamic compromise may rationalize elective utilization of MCS during TAVR.