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Rotational atherectomy (RA) is often used for lesion preparation in patients with moderate-severe coronary artery calcification (CAC). To reduce adverse effects, protected PCI with mechanical circulatory support with a percutaneous left ventricular assist device (pLVAD) (Impella, Abiomed, Danvers, MA) can be used during revascularization of complex high risk indicated patients (CHIP). Clinical trial data showed an association with increased adverse effects in patients being treated with RA who had an Impella pLVAD. We sought to examine the safety and efficacy of RA in real-world patients with CAC undergoing PCI with pLVAD support.
This observational, multicenter study assessed RA in patients with CAC with pLVAD or intra-aortic balloon pump (IABP) at the time of PCI. 38910 patients from 5 tertiary care hospitals who had PCI between January 2011 and January 2017 were identified. After performing propensity score matched analysis, all patients with pLVAD or IABP, who had RA prior to PCI were included in our analysis (n=46).
There were 25 patients in the IABP cohort and 21 patients in the pLVAD group. There was no significant difference in the primary endpoint, death on discharge (9.5% vs. 0%, p=0.15) with multivariate adjusted analysis. There were no significant differences in angiographic complications or secondary in-hospital endpoints including myocardial infarction or bleeding [Table 1].
|Variable Name||IABP(N=21)||pLVAD (N=21)||OR (95% CI)||p-value|
|Fluoroscopy Time (min)||29.2 +/- 14.5||31.9 +/- 22.1||n/a||0.65|
|Contrast Volume (ml)||160.6 +/- 56.0||134.2 +/- 41.4||n/a||0.09|
|Significant Dissection||1 (4.8%)||0 (0%)||0.95 (0.86-1.05)||0.33|
|Perforation||1 (4.8%)||0 (0%)||0.95 (0.86-1.05)||0.33|
|In-Hospital Mortality||2 (9.5%)||0 (0%)||0.90 (0.79-1.04)||0.15|
|Myocardial Infarction||2 (9.5%)||6 (31.6%)||4.38 (0.76-25.2)||0.08|
|Congestive Heart Failure||5 (23.8%)||0 (0%)||0.76 (0.59-0.97)||0.02|
|Blood Transfusion||7 (33.3%)||7 (33.3%)||1.16 (0.32-4.28)||0.82|
|Length of Stay (Days)||6.9 +/- 9.8||4.8 +/- 6.0||N/A||0.04|
In this real-world, multi-center analysis of CHIP patients with CAC undergoing RA with mechanical circulatory support, patients treated with pLVAD demonstrated non-inferiority compared to IABP, with an association of reduced length of stay and a trend towards improved survival to discharge. Mechanical support with pLVAD during RA in this high risk patient population, may allow for more complete revascularization with improved hemodynamic support.
CORONARY: Hemodynamic Support and Cardiogenic Shock