Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock

BackgroundTo investigate the feasibility and outcomes of Impella 2.5 support in patients with severe aortic valve stenosis (AS) and cardiogenic shock (CS), who underwent emergency percutaneous balloon aortic valvuloplasty (BAV) with or without percutaneous coronary intervention (PCI).Methods and resultsWe retrospectively analyzed a consecutive series of patients with severe AS and CS who underwent Impella 2.5 support following emergency BAV with or without subsequent PCI. Outcome data included 30-day outcomes, periprocedural as well as throughout the circulatory support period complications. Eight patients with severe AS and CS were identified. Impella 2.5 implantation was successful following emergency BAV in all patients attempted. Additional PCI was performed in four patients. No periprocedural deaths or periprocedural neurologic events occurred. Mean procedure time was 125.9 min (range 64–210 min). Mortality at 30 days was 50%.ConclusionsImpella 2.5 can be used as hemodynamic support in patients with severe AS and CS following emergency percutaneous BAV and may help to improve tolerability of PCI in these high-risk patients.     

Emergency balloon aortic valvuloplasty in patients with critical aortic stenosis presenting with cardiogenic shock.

This report describes 2 cases of aortic valvuloplasty performed as emergency treatment in patients with critical aortic stenosis presenting with cardiogenic shock. This procedure can be life-saving, and allows the patients to undergo further evaluation for aortic valve replacement, or other definitive treatments such as the recently developed percutaneous heart valve implantation for patients with unacceptably high surgical risk.     

Treatment of calcific aortic stenosis by balloon valvuloplasty

Recent reports have established the feasibility of using balloon valvuloplasty to reduce left ventricular outflow tract obstruction due to a calcified aortic valve. The present study summarizes experiences with this technique in 9 patients (7 women, 2 men, mean age 78 years) in whom balloon valvuloplasty was used to treat calcific aortic stenosis. Peak aortic valve gradient (mm Hg) decreased from 68 +/- 8 (mean +/- standard error of the mean) before valvuloplasty to 35 +/- 5 after valvuloplasty (p = 0.003). Mean aortic valve gradient decreased from 57 +/- 7 before valvuloplasty to 30 +/- 5 after valvuloplasty (p = 0.006). Calculated aortic valve area increased from 0.42 +/- 0.04 to 0.81 +/- 0.06 cm2 (p = 0.005). Balloon valvuloplasty failed to diminish aortic valve obstruction in only 1 patient who, at subsequent surgery, had a congenitally bicuspid aortic valve. Significant aortic regurgitation was not observed in any of the 9 patients after valvuloplasty. One patient did have a highly focal, presumably embolic, brain stem infarct during the procedure. Femoral arterial blood loss, related to wire-guided exchange of balloon catheters too large for a 12Fr introducer sheath, was minimized by direct arterial exposure in 8 of the 9 patients. Thus, these findings confirm the efficacy of balloon valvuloplasty for the treatment of calcific aortic stenosis. The procedure, however, is not without hazard.     

Successful aortic balloon valvuloplasty in critical aortic stenosis with shock

Emergency balloon valvuloplasty was performed in a 42 year old male with critical aortic stenosis, severe congestive heart failure, and shock. Hemodynamic and clinical improvement occurred and he underwent elective aortic valve replacement. Balloon aortic valvuloplasty may provide a “bridge” to aortic valve replacement in patients with critical aortic stenosis and shock. © 1993 Wiley-Liss, Inc.     

Efficacy of balloon valvuloplasty in patients with critical aortic stenosis and cardiogenic shock--the role of shock duration

BACKGROUND: Because of limited long-term success, aortic balloon valvuloplasty is considered to be a palliative procedure, including patients at excessive risk for standard therapy-aortic valve replacement-that is, those in cardiogenic shock. HYPOTHESIS: The study was undertaken to evaluate the outcome of balloon valvuloplasty for critical aortic stenosis complicated by cardiogenic shock. METHODS: Over a 10-year-period, we followed 14 patients (age 74+/-11 years, range 50-91) presenting in cardiogenic shock and critical aortic stenosis, who underwent valvuloplasty, together with 19 patients with critical aortic stenosis requiring urgent major noncardiac surgery. RESULTS: In patients in shock, calculated aortic valve area could be increased successfully by at least 0.3 cm2, from 0.38+/-0.09 to 0.81+/-0.12 cm2, with an insignificant increase in cardiac index from 1.89+/-0.33 to 2.01+/-0.41 l/min * m2. In-hospital mortality was 71% (10 patients). Two patients underwent valve replacement within 16 days and survived after 1 year, as did two patients refusing surgery. By multivariate logistic regression analysis, only an interval between onset of shock symptoms and valvuloplasty of > 48 h was significantly associated with fatal outcome (p < 0.01). In those patients requiring noncardiac surgery, this was possible after valvuloplasty in 95% who survived 1 year after hospital discharge. One patient in this group died of pulmonary embolism the day after the procedure. CONCLUSION: These data support the concept of causal treatment in patients with cardiogenic shock, as well as in the setting of cardiogenic shock and critical aortic stenosis, at the earliest possible convenience.     

Repeat balloon aortic valvuloplasty

This paper attempts to determine limitations and indications of performing a second balloon aortic valvuloplasty procedure (BAV2) because of restenosis, which is the major limitation of this technique. From September 1985 to December 1989, 357 patients underwent a primary BAV (BAV1) and 67 patients had a BAV2. Forty-two patients (group A) had repeat catheterization because they were markedly symptomatic 11 ± 7 months after BAV1. Twenty-five patients (group B) came from a group of 73 patients who had been systematically scheduled for repeat catheterization in order to evaluate the hemodynamic restenosis rate 8 ± 3 months after BAV. At time of BAV2 most of the patients of group A were severely disabled. Comparison of pre-BAV2 gradient and aortic valve area with pre-BAV1 measurements showed in a slightly less severe degree of aortic stenosis in group A and in group B with any difference in cardiac index and ejection fraction. Immediately following BAV2, the gradient decreased from 72 ± 22 to 33 ± 15 mm Hg (P ± and aortic valve area increased from 0.56 ± 0.18 to 0.85 ± 0.28 cm ²) (p < 0.001) in group A. In group B, gradient decreased from 68 ± 15 to 33 ± 15 mm Hg (p < 0.001) and aortic valve area increased from 0.70 ± 0.16 to 0.90 ± 0.25 cm² (p < 0.001). Comparison of the post-BAV2 peak systolic gradient, aortic valve area, ejection fraction, and cardiac index with post-BAV1 measurements revealed no significant differences in the two groups, but the absolute increase in aortic valve area obtained at BAV2 was significantly less than at BAV1 in group B (0.20 ± 0.22 vs 0.31 ± 0.16 cm² p < 0.02). The larger balloon size used for BAV2 than for BAV1 did not increase the final valve area at BAV2. In-hospital mortality was 3%. The use of a better profiled catheter with an arterial introducer explained the lower rate of vascular complications (4%). This report demonstrates that when BAV is indicated a second procedure can be performed safely and with low risk in symptomatic patients. © 1992 Wiley-Liss, Inc.     

Impella-assisted balloon aortic valvuloplasty

The Impella LP 2.5 left ventricular assist device (Abiomed) is safe and effective for assisting high-risk percutaneous interventions. A 77-year-old woman with severe aortic stenosis, severe coronary artery disease, an ejection fraction of 20%, severe peripheral vascular disease, and other comorbidities presented to a private, tertiary referral hospital with shortness of breath that had been worsening over 2 weeks. The patient underwent a successful, Impella-assisted balloon aortic valvuloplasty (BAV) without complications. Impella support may be considered during BAV in high-risk patients with contraindications for a TandemHeart device (CardiacAssist, Inc.).     

Life-saving balloon mitral valvuloplasty in patient with cardiogenic shock after cardiac arrest.

Balloon mitral valvuloplasty is the procedure of choice in a selected group of patients with significant mitral stenosis and suitable valve morphology. Experience in patients with cardiogenic shock is very limited. We report the case of a dying patient in cardiogenic shock, with pulmonary edema and severe hepatic damage after cardiac arrest caused by mitral restenosis. The patient was successfully treated by emergency balloon mitral valvuloplasty with a good result and complete recovery.     

Combined PTCA and aortic valvuloplasty for acute myocardial infarction complicated by severe aortic stenosis and cardiogenic shock

Percutaneous aortic valvuloplasty (PAV) performed in patients with critical aortic stenosis has been shown to increase aortic valve area, decrease aortic valve gradient, and improve left ventricular function. However, the procedure is limited by rapid restenosis. Aortic valvuloplasty in the setting of critical aortic stenosis with cardiogenic shock can be a life-saving procedure, although morbidity and mortality remain high. We describe a patient with critical aortic stenosis who presented with an acute anterior myocardial infarction treated with primary angioplasty. Despite rapidly achieving patency of the culprit vessel, the patient spiraled into cardiogenic shock, which prompted an emergent PAV. Cathet. Cardiovasc. Diagn. 42:283–285, 1997. © 1997 Wiley-Liss, Inc.     

Trefoil balloon for aortic valvuloplasty

A new balloon for valvuloplasty (Trefoil balloon) was successfully used in a 12 year old boy with congenital aortic stenosis. The Trefoil balloon consists of three angioplasty balloons mounted in parallel on a single shaft. When they are inflated simultaneously they produce a rosette that allows blood flow to continue through the valve. The aortic pressure only dropped to 75 mm Hg during a 15 s balloon dilatation at 4 bar (400 kPa). The procedure reduced the transvalvar gradient from 45 to 15 mm Hg.     

Repeat balloon aortic valvuloplasty.

This paper attempts to determine limitations and indications of performing a second balloon aortic valvuloplasty procedure (BAV2) because of restenosis, which is the major limitation of this technique. From September 1985 to December 1989, 357 patients underwent a primary BAV (BAV1) and 67 patients had a BAV2. Forty-two patients (group A) had repeat catheterization because they were markedly symptomatic 11 +/- 7 months after BAV1. Twenty-five patients (group B) came from a group of 73 patients who had been systematically scheduled for repeat catheterization in order to evaluate the hemodynamic restenosis rate 8 +/- 3 months after BAV. At time of BAV2 most of the patients of group A were severely disabled. Comparison of pre-BAV2 gradient and aortic valve area with pre-BAV1 measurements showed in a slightly less severe degree of aortic stenosis in group A and in group B with any difference in cardiac index and ejection fraction. Immediately following BAV2, the gradient decreased from 72 +/- 22 to 33 +/- 15 mm Hg (P less than 0.001) and aortic valve area increased from 0.56 +/- 0.18 to 0.85 +/- 0.28 cm2 (p less than 0.001) in group A. In group B, gradient decreased from 68 +/- 15 to 33 +/- 15 mm Hg (p less than 0.001) and aortic valve area increased from 0.70 +/- 0.16 to 0.90 +/- 0.25 cm2 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of cardiogenic shock in myocardial infarction by intraaortic balloon counterpulsation surgery.

Thirty-seven patients in cardiogenic shock due to acute myocardial infarction were treated with intraaortic balloon counterpulsation and/or surgery. Eighteen of these patients were treated with counterpulsation alone; eight survived and five were in functional class I or II at the time of follow-up; two were in functional class III, and one was in functional class IV. Nineteen patients were treated surgically, eight survived and seven were in functional class I or II at the time of follow-up; one was in functional class III. Good functional recovery with counterpulsation alone is most common with inferior infarction. With surgery, functional recovery depends not only on the extent of the infarction and the coronary anatomy, but also on the ability to perform surgery within 12 hours of infarction or to support the patient with mechanical means for 10 to 14 days after the infarction and then perform surgery.     

体外膜肺氧合结合球囊房间隔造口左心减压治疗心源性休克

体外膜肺氧合(Extracorporeal membrane oxygen, ECMO)在重症心肺功能衰竭患者生命支持方面的应用越来越普遍,未来有可能成为常规的治疗手段。经房间隔球囊扩张制造房间隔缺损方式达成左心减容减压的方法,在心源性休克的治疗方面表现出良好的效果,但目前很少有文献报道。本文报道一例我院在该技术方面的应用经验。     

Percutaneous balloon aortic valvuloplasty during pregnancy

Severe aortic stenosis may potentiate sudden life threatening complications during pregnancy. We report a case of successful percutaneous balloon aortic valvuloplasty in a pregnant patient with severe symptomatic aortic stenosis due to congenital bicuspid aortic valve at 14 weeks' gestation. Use of percutaneous valvuloplasty allowed asymptomatic progression of the pregnancy to term and normal delivery of a healthy 2920 g infant.