Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect

TY - JOUR

T1 - Hemodynamic Effects of Mechanical Circulatory Support Devices in Ventricular Septal Defect

AU - Pahuja, Mohit

AU - Schrage, Benedikt

AU - Westermann, Dirk

AU - Basir, Mir B

AU - Garan, Arthur Reshad

AU - Burkhoff, Daniel

PY - 2019/7

Y1 - 2019/7

N2 - BACKGROUND: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown.METHODS AND RESULTS: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS.CONCLUSIONS: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.

AB - BACKGROUND: Ventricular septal defect (VSD) is a lethal complication of acute myocardial infarction (AMI) and is often associated with cardiogenic shock. The optimal form of percutaneous mechanical circulatory support (MCS) for AMI-VSD is unknown.METHODS AND RESULTS: We used a previously validated cardiovascular model to simulate AMI-VSD with parameters adjusted to replicate average hemodynamics reported in the literature, including a pulmonary-to-systemic blood flow ratio of 3.0. We then predicted effects of different types of percutaneous MCS (including intra-aortic balloon pumping, Impella, TandemHeart, and extracorporeal membrane oxygenation) on pressures and flows throughout the cardiovascular system. The simulation replicated all major hemodynamic parameters reported in the literature with AMI-VSD. Inotropes and vasopressors worsened left-to-right shunting, whereas vasodilators decreased shunting at the expense of worsening hypotension. All MCS devices increased forward blood flow and arterial pressure but other effects varied among devices. Impella 5.0 provided the greatest degree of pulmonary capillary wedge pressure reductions and decreased left-to-right shunting. Extracorporeal membrane oxygenation worsened pulmonary capillary wedge pressure and shunting, which could be improved by adding Impella or passive left ventricular vent. Pulmonary-to-systemic blood flow ratio could not be reduced below 2.0, and pulmonary flows remained high with all forms of MCS.CONCLUSIONS: Although no form of percutaneous MCS normalized hemodynamics in AMI-VSD, pulmonary capillary wedge pressure and shunting were worsened by extracorporeal membrane oxygenation and improved by Impella. Accordingly, based on hemodynamics alone, Impella provides the optimal form of support in AMI-VSD. However, other factors, including team experience, device availability, potential for tissue ingestion, and clinical characteristics, need to be considered when choosing a percutaneous MCS device for AMI-VSD.

KW - Adult

KW - Aged

KW - Aged, 80 and over

KW - Extracorporeal Membrane Oxygenation/instrumentation

KW - Female

KW - Heart Failure/physiopathology

KW - Heart Septal Defects, Ventricular/physiopathology

KW - Heart Ventricles/physiopathology

KW - Heart-Assist Devices/adverse effects

KW - Hemodynamics/physiology

KW - Humans

KW - Intra-Aortic Balloon Pumping/adverse effects

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/physiopathology

KW - Risk Factors

KW - Shock, Cardiogenic/physiopathology

U2 - 10.1161/CIRCHEARTFAILURE.119.005981

DO - 10.1161/CIRCHEARTFAILURE.119.005981

M3 - SCORING: Journal article

C2 - 31296094

VL - 12

SP - e005981

JO - CIRC-HEART FAIL

JF - CIRC-HEART FAIL

SN - 1941-3289

IS - 7

ER -