Veno-arterial extracorporeal membrane oxygenation with concomitant Impella versus concomitant intra-aortic-balloon-pump for cardiogenic shock.

INTRODUCTION: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. METHODS: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. RESULTS: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. CONCLUSIONS: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.

Alpha-Loop Snaring Technique: Facilitated Snaring Technique for Fully-Deployed and Deformed Coronary Stent Protruding Into the Aorta.

A 59-year-old female was admitted for non-ST-segment elevation myocardial infarction and Killip class 3 heart failure with a left ventricular ejection fraction of 30%. Coronary angiogram showed moderate to severe stenosis over the ostial-proximal left anterior descending artery with minor disease over the left circumflex artery and right coronary artery. We describe a complication encountered where a protruding stent was weakened and elongated during our attempts to remove it, risking possible breakage, stent embolization, and long stent protrusion inside the aorta. We then describe treatment with what we call the alpha-loop snaring technique, which, to our knowledge, is the first report describing this novel approach, which can salvage a failing snaring attempt of a completely deployed and dislodged coronary stent.

A Case of Rota-Shock-Pella.

Severe calcified coronary lesions are frequently encountered in today's percutaneous coronary intervention practice and remain a challenging entity in complex and high-risk patients. The present case illustrates the contemporary approach to management of this coronary problem from hemodynamic support, optical coherence tomography assessment, and plaque modification technique. (Level of Difficulty: Advanced.).