Left ventricular unloading therapy using Impella 5.5 after emergency surgery for acute myocardial infarction mechanical complication: a case report
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SUBMITTER: Iino K
PROVIDER: S-EPMC11202249 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality. Pioneering preclinical work reported by Peter Maroko and Eugene Braunwald in 1971 identified oxygen supply and demand are primary determinants of myocardial infarct size in the setting of a heart attack. Since the 1950s, advances in mechanical engineering led to the development of short-term circulatory support devices that range from pulsatile to continuous flow pumps. The primary objective of these pumps is to reduce native heart work, enhance coronary blood flow, and sustain systemic perfusion. Whether these pumps could reduce myocardial infarct size in the setting of AMI became an intense focus for preclinical investigation with variable animal models, experimental algorithms, and pump platforms being tested. In this review, we discuss the design of these preclinical studies and the evolution of mechanical support platforms and attempt to translate these experimental methods into clinical trials.
| S-EPMC7608694 | biostudies-literature
Project description:BackgroundHeart failure after an acute myocardial infarction (AMI) is a major cause of morbidity and mortality worldwide. We recently reported that activation of a transvalvular axial-flow pump in the left ventricle and delaying myocardial reperfusion, known as primary unloading, limits infarct size after AMI. The mechanisms underlying the cardioprotective benefit of primary unloading and whether the acute decrease in infarct size results in a durable reduction in LV scar and improves cardiac function remain unknown.ObjectivesThis study tested the importance of LV unloading before reperfusion, explored cardioprotective mechanisms, and determined the late-term impact of primary unloading on myocardial function.MethodsAdult male swine were subjected to primary reperfusion or primary unloading after 90 min of percutaneous left anterior descending artery occlusion.ResultsCompared with primary reperfusion, 30 min of LV unloading was necessary and sufficient before reperfusion to limit infarct size 28 days after AMI. Compared with primary reperfusion, primary unloading increased expression of genes associated with cellular respiration and mitochondrial integrity within the infarct zone. Primary unloading for 30 min further reduced activity levels of proteases known to degrade the cardioprotective cytokine, stromal-derived factor (SDF)-1α, thereby increasing SDF-1α signaling via reperfusion injury salvage kinases, which limits apoptosis within the infarct zone. Inhibiting SDF-1α activity attenuated the cardioprotective effect of primary unloading. Twenty-eight days after AMI, primary unloading reduced LV scar size, improved cardiac function, and limited expression of biomarkers associated with heart failure and maladaptive remodeling.ConclusionsThe authors report for the first time that first mechanically reducing LV work before coronary reperfusion with a transvalvular pump is necessary and sufficient to reduce infarct size and to activate a cardioprotective program that includes enhanced SDF-1α activity. Primary unloading further improved LV scar size and cardiac function 28 days after AMI.
| S-EPMC6817809 | biostudies-literature
Project description:BackgroundThe Impella 5.5® was approved by the FDA for use for mechanical circulatory support up to 14 days in late 2019 at limited centers in the United States. Our single center's experience with Impella 5.5® can expand the overall understanding for achieving successful patient outcomes as well as provide support for the expansion of its FDA-approved use.MethodsThis study is an IRB-approved single-center retrospective cohort analysis of hospitalized adult patient characteristics and outcomes in cases where the Impella 5.5® was utilized for mechanical circulatory support.ResultsA total of 26 implanted Impella 5.5® devices were identified in 24 hospitalized patients at our institution from January 2020 to January 2021. The overall survival rate during index hospitalization was 75%. Eleven Impella 5.5® devices were identified in 10 patients with an average device implantation greater than 14 days. Average device implantation for this subgroup was 27 days with a range of 15-80 days. Survival rate for Impella 5.5® use greater than 14 days was 67%. In the entire cohort and subgroup of device implantation > 14 days, evidence of end organ damage improved with Impella 5.5® use. Complications in our cohort and subgroup of device implantation > 14 days were similar to previously reported complication incidence of axillary inserted LVAD devices.ConclusionsOur institution's experience with the Impella 5.5® has been strongly positive with favorable outcomes and helps to establish the Impella 5.5® as a viable option for mechanical circulatory support beyond 14 days.
| S-EPMC9128113 | biostudies-literature
Project description: Not available
| S-EPMC9050574 | biostudies-literature
Project description:BackgroundIntramyocardial dissecting hematoma (IDH) is a rare mechanical complication following myocardial infarction (MI), and only a few isolated cases have been reported to date. IDH presents with diverse clinical manifestations, often resulting in missed or misdiagnosed cases due to limited physician understanding. The diagnosis and treatment of IDH is a major challenge.Case presentationsWe report a case of acute extensive anterior MI in a 73-year-old woman, who underwent percutaneous coronary intervention (PCI); the left ventricular intramyocardial dissecting hematoma (LVIDH) penetrated the right ventricular outflow tract (RVOT), resulting in thrombus formation and subsequent RVOT obstruction. Clinically insignificant IDH was detected by transthoracic echocardiography (TTE) at 3 days, 43 days, and 75 days post-PCI, with characteristic changes in the left ventricular wall ultrasound images. This unusual case highlights the important role of continuous transthoracic echocardiography in identifying this rare complication of LVIDH. After a detailed discussion with the patient, the choice between conservative or surgical management of IDH depends on factors such as the size of the hematomae, left ventricular systolic function, and the patient's clinical and haemodynamic status. In this particular case, conservative management was chosen by the patient who declined surgery but unfortunately succumbed to cardiogenic shock.ConclusionsThis case describes a rare complication of acute myocardial infarction (AMI) and also focuses on the utility of TTE in the diagnosis of this rare complication. Whether LVIDH is treated conservatively or surgically requires careful evaluation to achieve the best prognosis for the patient.
| S-EPMC11465562 | biostudies-literature
Project description:BackgroundMyocardial damage due to acute ST-segment elevation myocardial infarction (STEMI) remains a significant global health problem. New approaches to limit myocardial infarct size and reduce progression to heart failure after STEMI are needed. Mechanically reducing left ventricular (LV) workload (LV unloading) before coronary reperfusion is emerging as a potential approach to reduce infarct size.ObjectivesGiven the central importance of mitochondria in reperfusion injury, we hypothesized that compared with immediate reperfusion (IR), LV unloading before reperfusion improves myocardial energy substrate use and preserves mitochondrial structure and function.MethodsTo explore the effect of LV unloading duration on infarct size, we analyzed data from the STEMI-Door to Unload (STEMI-DTU) trial and then tested the effect of LV unloading on ischemia and reperfusion injury, cardiac metabolism, and mitochondrial function in swine models of acute myocardial infarction.ResultsThe duration of LV unloading before reperfusion was inversely associated with infarct size in patients with large anterior STEMI. In preclinical models, LV unloading reduced the expression of hypoxia-sensitive proteins and myocardial damage due to ischemia alone. LV unloading with a transvalvular pump (TV-P) but not with venoarterial extracorporeal membrane oxygenation (ECMO) reduced infarct size. Using unbiased and blinded metabolic profiling, TV-P improved myocardial energy substrate use and preserved mitochondrial structure including cardiolipin content after reperfusion compared with IR or ECMO. Functional testing in mitochondria isolated from the infarct zone showed an intact mitochondrial structure including cardiolipin content, preserved activity of the electron transport chain including mitochondrial complex I, and reduced oxidative stress with TV-P-supported reperfusion but not with IR or ECMO.ConclusionsThese novel findings identify that transvalvular unloading limits ischemic injury before reperfusion, improves myocardial energy substrate use, and preserves mitochondrial structure and function after reperfusion.
| S-EPMC10243472 | biostudies-literature
Project description:Here, we report a case of ventricular septal perforation complicated with right ventricular infarction after inferior acute myocardial infarction, which was associated with a poor clinical outcome despite the successful surgical treatment.
| S-EPMC10577155 | biostudies-literature
Project description:Heart failure is a major cause of morbidity and mortality around the world, and myocardial infarction is its leading cause. Myocardial infarction destroys viable myocardium, and this dead tissue is replaced by a non-contractile scar that results in impaired cardiac function and a significantly increased likelihood of the patient developing heart failure. Limiting infarct scar size has been the target of pre-clinical and clinical investigations for decades. However, beyond reperfusion, few therapies have translated into the clinic that limit its formation. New approaches are needed. This review will focus on new clinical and pre-clinical data demonstrating that acute ventricular unloading prior to reperfusion by means of percutaneous left ventricular support devices reduces ischemia-reperfusion injury and limits infarct scar size. Emphasis will be given to summarizing our current mechanistic understanding of this new therapeutic approach to treating myocardial infarction.
| S-EPMC6497619 | biostudies-literature
Project description:BackgroundLeft ventricular assist device (LVAD) mechanically unloads the left ventricle (LV). Theoretical analysis indicates that partial LVAD support (p-LVAD), where LV remains ejecting, reduces LV preload while increases afterload resulting from the elevation of total cardiac output and mean aortic pressure, and consequently does not markedly decrease myocardial oxygen consumption (MVO2). In contrast, total LVAD support (t-LVAD), where LV no longer ejects, markedly decreases LV preload volume and afterload pressure, thereby strikingly reduces MVO2. Since an imbalance in oxygen supply and demand is the fundamental pathophysiology of myocardial infarction (MI), we hypothesized that t-LVAD minimizes MVO2 and reduces infarct size in MI. The purpose of this study was to evaluate the differential impact of the support level of LVAD on MVO2 and infarct size in a canine model of ischemia-reperfusion.MethodsIn 5 normal mongrel dogs, we examined the impact of LVAD on MVO2 at 3 support levels: Control (no LVAD support), p-LVAD and t-LVAD. In another 16 dogs, ischemia was induced by occluding major branches of the left anterior descending coronary artery (90 min) followed by reperfusion (300 min). We activated LVAD from the beginning of ischemia until 300 min of reperfusion, and compared the infarct size among 3 different levels of LVAD support.Resultst-LVAD markedly reduced MVO2 (% reduction againstControl-56 ± 9%, p<0.01) whereas p-LVAD did less (-21 ± 14%, p<0.05). t-LVAD markedly reduced infarct size compared to p-LVAD (infarct area/area at risk: CONTROL; 41.8 ± 6.4, p-LVAD; 29.1 ± 5.6 and t-LVAD; 5.0 ± 3.1%, p<0.01). Changes in creatine kinase-MB paralleled those in infarct size.ConclusionsTotal LVAD support that minimizes metabolic demand maximizes the benefit of LVAD in the treatment of acute myocardial infarction.
| S-EPMC4849631 | biostudies-literature
Project description:Intramyocardial dissecting haematoma is a rare complication of myocardial infarction (MI) associated with high mortality rates. Studies and research of this occurrence are limited largely to isolated case reports or case series. We report a case of late presenting MI, where on initial echocardiogram had what was thought to be an intraventricular clot. However, upon further evaluation, the patient actually had an intramyocardial haematoma, with the supporting echocardiographic features to distinguish it from typical left ventricular (LV) clot. While this prevented the patient from receiving otherwise unnecessary anticoagulation, this diagnosis also put him at a much higher risk of mortality. Despite exhaustive medical and supportive management, death as consequence of pump failure occurred after 2 weeks. This report highlights the features seen on echocardiography which support the diagnosis of an intramyocardial haematoma rather than an LV clot, notably the various acoustic densities, a well visualized myocardial dissecting tear leading into a neocavity filled with blood, and an independent endocardial layer seen above the haematoma. Based on this report, we wish to highlight the importance of differentiating intramyocardial haematomas from intraventricular clots in patients with recent MI.
| S-EPMC6601172 | biostudies-literature