Complex and High-Risk Percutaneous Intervention Assisted By Extracorporeal Membrane Oxygenation (ECMO)
Abstract
Background: Despite improvements in percutaneous coronary artery techniques (PCI) and equipment, traditional PCI alone is still insufficient to manage complex and high-risk lesions due to increased risk of major adverse cardiac events, including myocardial infarction, cardiogenic shock, and death. In recent years, the use of extracorporeal membrane oxygenation (ECMO) during PCI has emerged as a potential solution to manage complex and high-risk lesions.
Objective: To examine the in-hospital and 1-year clinical outcomes in patients who underwent complex, high-risk PCI with VA-ECMO support.
Methods: This retrospective study included patients who underwent elective complex and high-risk PCI with hemodynamic support provided by VA-ECMO from 2018 to 2022. Rates of VA-ECMO related complications, complications related to PCI, death, and MACCE events during hospitalization and after one-year follow-up were analyzed.
Results: A total of 81 patients (Average age: 62.74 ±10.807 years) underwent complex and high-risk PCI assisted with ECMO. The VA-ECMO support was provided for an average of 21.0 hours (With a range of 1-312). Intra-aortic Balloon Pump IABP support was provided in 32.1% of patients. The pre-and post-PCI SYNTAX scores of the patients were 39.92 ± (6.4) and 6.04 ± (9.25), respectively (P ˂0.001). Most of the patients had triple-vessel coronary disease (47%). Interoperated complications include Cardiac Tamponade (N=1,1.2%), Acute Myocardial Infarction (N=6,7.2%), Cardiogenic Shock (N=2,2.4%), Cardiac Arrest (N=2,2.4%), Arrhythmias malignant in nature which required electro cardioversion (2,2.4%), Ventricular tachycardia (N=1,1.2%), Non-infectious multiple organ failure MODS(N=1,1.2%), Aortic Dissection Type-A (N=1,1.2%). Blood hemoglobin Pre- CHIP assisted VA-ECMO PCI and Post-procedure were 136.17 ± 21.479 g/L and 106.67 ± 19.103 g/L respectively P<0.001). eGFR pre and post-PCI were 67.22 ± 26.85 and 60.09 ± 27.78 respectively (<0.002), Pre and Post PCI EF were 38.69 ± 13.65 and 43.55 ± 13.72 respectively (<0.001), During hospitalization the outcomes for the CHIP assisted by ECMO procedure include Death (N=16,19.8%), Inguinal Hematoma (N=2,2.5%), Bleeding from the punctured site (N=2,2.5%), Pseudoaneurysm (N=1,1.2%), Cerebral Infarction(N=1,1.2%), Subarachnoid hemorrhage (N=1,1.2%). Lower limb ischemia, acute renal injury, and Bacteremia were not observed in any of the hospitalized patient. Hemoglobin level (Hb) was decline in 72.8% of patients requiring blood transfusion therapy was (N=59). Survival at discharge (Healthy) was (N=65, 80.2%). In 1 year of follow-up, six patients died (6, 7.5%), including 1 patient who died of ventricular fibrillation after discharge, 1 patient died of aortic stenosis after 1 month of high-risk PCI, 1 patient died of terminal illness, 1 patient had recurrent acute myocardial infarction 6 months after PCI (stent restenosis), another died of acute heart failure after 28 days, and another died of multiple organ dysfunction syndrome (MODS).
Conclusion: ECMO-assisted support during high-risk PCI is a safe and effective strategy for achieving revascularization in complex and high-risk coronary artery lesions in patients who are not candidates for CABG. The use of VA-ECMO resulted in minimal complications and low rates of MACCE during hospitalization and one-year follow-up. Further research is needed to determine the optimal timing for VA-ECMO initiation
