Introduction: Rotational atherectomy (RA) is frequently used for plaque modification in patients with calcified coronary lesions. RA use in dominant artery lesions is often associated with transient bradyarrhythmias, thought to be due to adenosine release from injured erythrocytes. As such, prophylactic transvenous pacemakers (TVP) are often placed, increasing risk of bleeding and tamponade. We hypothesize that patients undergoing RA at risk for bradyarrhythmias can be safely managed with non-selective adenosine receptor antagonists without routine prophylactic TVP use. Methods: We retrospectively identified 384 consecutive patients who underwent RA at the Ralph H. Johnson VA Medical Center between January 2011 and September 2020. Patients were divided into those pretreated with aminophylline or theophylline (n=147) and those who were not. Primary and secondary endpoints were breakthrough bradyarrhythmia requiring acute pharmacologic or TVP rescue and a composite of 30-day cardiovascular mortality, readmission, and permanent pacemaker implantation. Results: A total of 319 patients who underwent 358 RA procedures met our inclusion criteria. None of the patients had a prophylactic TVP. Overall, 25 patients (6.9%) developed bradycardia, all successfully managed pharmacologically without TVP rescue. Of those pretreated, significantly more patients (12.2%) developed breakthrough bradycardia compared to the 3.3% that did not receive pretreatment (P value 0.001). RA on a dominant vessel was the only significant risk factor among those who developed bradycardia. There was no difference in the secondary endpoint between those pretreated with a non-selective adenosine receptor antagonist compared to those that were not (P value 0.09). Conclusion: Plaque modification with RA can be safely done without routine prophylactic TVP use with favorable acute procedural and short-term outcomes with aminophylline or theophylline pretreatment. There is a significant risk of breakthrough bradycardia with RA on a dominant vessel that can be easily managed medically.

Objectives: The use of percutaneous mechanical circulatory support (PMCS) devices offers a means to maintain hemodynamic stability in pre-transplant patients. The Impella Heart Pump and the intra-aortic balloon pump (IABP) are two devices commonly employed for this purpose. We sought to compare the relative safety and efficacy of Impella vs IABP using a retrospective cohort of patients at our institution from 2014-2021. Methods: 239 patients received Impella support, and 220 patients received IABP. Of these patients, 26 receiving Impella and 49 receiving IABP were identified as pre-transplant/VAD. The incidences of 30-day mortality, major bleeding, hemolysis, limb ischemia, stroke, repositioning, and infection were recorded. The number of patients receiving transplants, VADs, Mechanical Circulatory Support escalation, and ECMO were also recorded. The relative risks of complications were calculated, and an alpha of 0.05 was assigned to identify significance. Results: The average age of the IABP group was 54.8 +/- 12.1 years with 39 males to 10 females. The average age of the Impella group was 44.8 +/- 15 years with 15 males to 11 females. There was no significant difference in pre-placement EF between these two groups (IABP EF = 19.28+/-8.62, Impella EF = 21.15+/-9.69; p = 0.4016). A significantly higher relative risk of mortality (RR = 3.23; 95% CI = 1.45-7.20, p = 0.0041), major bleeding (RR = 8.48; 95% CI = 3.2 - 22.45, p < 0.00001), and hemolysis (RR = 35.2; 95% CI = 2.12-582, p = 0.0128) was noted in patients receiving Impella support. No significant difference in the incidence of limb ischemia, stroke, repositioning, or infection was observed between these two groups. A significantly higher number of patients receiving Impella support also required ECMO (p = 0.0003) Conclusions: These data suggest that a higher risk of mortality or major complications may exist for patients receiving Impella support pre-transplant/VAD. Further analysis is needed to correct for baseline differences between these two cohorts.

No abstract