Best of heart failure

33 revascularization, adjunct pharmacologic support with inotropes or vasopres- sors may be required which in fact can worsen myocardial ischemia. In cases of severe CAD with high "Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery" (SYNTAX) score, LV dysfunction and/or planned for surgical revascularization, timely initiation of IABP support prior to CABG has been associated with better outcomes including perioperative mor- tality and all-cause 30-day mortality [ 23 ]. The Impella is an axial flow catheter placed into the LV in retrograde fashion across the aortic valve. The Impella transfers kinetic energy from a circulating impeller to the blood stream, which results in continuous blood flow from the left ventricle to the ascending aorta. The PROTECT II trial randomized 452 patients referred for non-emergent high-risk PCI to insertion of an Impella 2.5 or IABP before PCI. High-risk PCI was defined as a LVEF ≤ 35% and unprotected left main or last patent coronary conduit or LVEF G 30% with three-vessel coronary disease. Heart failure severity was based on LVEF and functional class (NYHA class III/IV 67% of the Impella group and 64% of the IABP group). The Impella 2.5 demonstrated superior hemodynamic support compared to IABP therapy. No difference in the primary endpoint (composite rate of intra- or post-procedural major adverse events at discharge or 30-day follow-up) was observed between groups (35% vs. 40%, Impella 2.5 vs. IABP, p = 0.227). At 90- day follow-up, a trend towards reduced MACE was observed in the Impella arm but not in the IABP arm (40.6% vs. 49.3%, p = 0.066) in the intention-to-treat population and (40% vs. 51%, p = 0.02) in the per-protocol population [ 24 ]. Since the completion of that trial, newer generation axial flow pumps with higher performance power have been developed, namely, the Impella CP and Impella 5.0. Data on assisted revascularization with these platforms are limited to case series, but it has been shown to be a feasible concept in patients with severe LV dysfunction. Lastly, VA-ECMO withdraws deoxygenated venous blood from the body and delivers it to a centrifugal pump. The pump then delivers this deoxygenated blood through an oxygenator and back into the arterial circulation. VA-ECMO can be initiated using central (surgical) or peripheral (percutaneous or surgical) access [ 25 ]. It provides circulatory support by displacing blood volume from the venous to the arterial circulation, which increases aortic systolic, diastolic, and mean arterial pressures. VA-ECMO, however, does not provide effective ven- tricular unloading. By pressurizing the arterial circulation, LV afterload is in- creased, and depending on native LV function, VA-ECMO may in fact be associated with increased LV end-diastolic pressures, potentially leading to or worsening pulmonary edema. To date, revascularization while on VA-ECMO has been reported in patients with LV dysfunction suffering from cardiopul- monary collapse or intractable arrhythmias. The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Trial demonstrated that durable, surgi- cally implanted left ventricular assist devices (LVADs) improved survival in patients with end-stage HF compared to medical therapy alone. Moreover, in 2009, continuous flow LVADs (CF-LVADs) showed significantly improved 2- year survival compared to pulsatile LVADS. Since then, the use of permanent CF-LVADs has grown exponentially to more than 2500 implants per year. In these patients, revascularization is practically an unknown topic given the paucity of available data. Chest pain on LVAD support is a complex 4 Page 8 of 12 Curr Treat Options Cardio Med (2019) 21: 4