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In short&#44; Impella<span class="elsevierStyleSup">&#174;</span> aspirates blood from the left ventricle &#40;LV&#41; into the ascending aorta&#44; thereby unloading the LV&#44; increasing aortic and intracoronary pressure and reducing end-diastolic wall stress&#46; The end result is a favorable effect on the supply&#8211;demand equilibrium of the myocardium at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> The PROTECT II<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> trial is the largest randomized trial comparing Impella<span class="elsevierStyleSup">&#174;</span> &#40;using Impella 2&#46;5<span class="elsevierStyleSup">&#174;</span>&#41; with an intraortic balloon counterpulsation to support nonemergent high-risk PCI&#46; The trial found no significant difference in major adverse events at discharge or 30 days&#44; but the per-protocol analysis revealed a strong trend toward decreased adverse events with Impella<span class="elsevierStyleSup">&#174;</span> at 90 days&#46; Therefore&#44; the use of Impella<span class="elsevierStyleSup">&#174;</span> during high-risk PCI may hold promise over the long term&#46; Notably&#44; in the Balloon Pump-Assisted Coronary Intervention Study&#44; an intraortic balloon counterpulsation pump failed to reduce major adverse cardiac and cardiovascular events in nonemergent high-risk PCI procedures compared to the conventional strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; is the new generation of the percutaneous&#44; catheter-based device that can provide a flow of up to 3&#46;5 l&#47;min&#46; Here&#44; we present two cases of high-risk PCI performed in our center with LV assistance provided by an Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0090" class="elsevierStylePara elsevierViewall">A 70-year-old diabetic male with a history of chronic kidney disease &#40;creatinine clearance 43 ml&#47;min&#41; was admitted to our cardiac intensive care unit with non-ST-elevation myocardial infarction&#44; Killip class III&#46; Thirty years previously&#44; he had undergone 3-vessel coronary artery bypass grafting &#40;CABG&#41; with saphenous vein grafts &#40;SVGs&#41; and had subsequently undergone PCI of the SVGs to the first obtuse marginal &#40;OM1&#41; in 2002 and 2009&#44; with implantation of a 4&#46;5&#215;13-mm Bx Velocity&#8482; stent &#40;Johnson &#38; Johnson&#41; and a 4&#46;0&#215;2&#46;8-mm Xience stent &#40;Abbott Vascular&#41;&#44; respectively&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On admission&#44; a transthoracic echocardiogram &#40;TTE&#41; showed severely depressed left ventricular ejection fraction &#40;LVEF&#41; &#40;estimated 29&#37;&#41;&#59; akinesis of the apex&#44; inferior wall&#44; middle and distal segments of the anterior wall&#59; and hypokinesis of the other walls&#46; There was no evidence of intracavitary thrombi&#46; Invasive coronary angiography revealed severe native coronary artery disease consisting of an occluded left anterior descending &#40;LAD&#41; artery at the origin and occluded left circumflex &#40;LCX&#41; and right coronary artery &#40;RCA&#41; in their middle segments&#46; The SVG to LAD was occluded&#44; the SVG to the OM1 had 90&#37; stenosis proximally &#40;pre-stent&#41; and the SVG to the right posterior descending artery had 70&#37; stenosis distally&#46; The patient underwent cardiac magnetic resonance imaging &#40;CMRI&#41;&#44; which showed extensive myocardial scarring involving the apex&#44; the inferior wall and the middle and distal segments of the anterior wall&#46; Finally&#44; an adenosine stress perfusion CMRI revealed ischemia of the basal segment of the inferolateral wall&#46; Based on this evidence&#44; and in an attempt to improve the patient&#39;s status&#44; it was decided to perform a PCI of the SVG to the OM1&#46; A 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was selected for support due to the low physiologic reserve of the patient and the relevance of the aforementioned graft in the perfusion of the remaining viable myocardium&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Following local anesthesia&#44; a 6-Fr sheath was inserted into the right femoral artery&#46; After performing a contrast study of the aorta and both iliac arteries&#44; the patient was considered a candidate for using the assist device&#46; A 14-Fr sheath was then placed in the left femoral artery&#46; After administration of 5000 units of unfractionated heparin &#40;UFH&#41;&#44; an angiographic pigtail diagnostic catheter &#40;Cardinal Health&#41; was used to deliver a specific 0&#46;14-inch guidewire to the LV&#46; The diagnostic catheter was then removed&#44; and the Impella CP<span class="elsevierStyleSup">&#174;</span> pump was advanced over the wire across the aortic valve under angiographic guidance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; The pump was started&#44; with a maximum of 3&#46;5 l per minute of circulatory support necessary to maintain the patient hemodynamically stable during the procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The SVG to the OM1 was intubated with a 6-Fr Amplatz Left 1 catheter &#40;Cardinal Health&#41;&#46; A distal embolic protection device&#44; the 6-Fr Emboshield NAV &#40;Abbott Vascular&#41;&#44; was gently passed into the SVG across the target lesion and was deployed at the distal portion of the graft &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; After pre-dilation of the target lesion with a 3&#46;5&#215;20-mm TREK balloon &#40;Abbott Vascular&#41;&#44; a 4&#46;0&#215;28-mm Xience stent was successfully deployed in the SVG&#46; Next&#44; the stent was post-dilated with a 4&#46;5&#215;15-mm Quantum&#8482; Maverick&#8482; balloon &#40;Boston Scientific&#41; at 18 atm&#46; The Emboshield NAV basket was then carefully withdrawn&#46; Aspiration was performed to clear the guide catheter of any debris and thrombi and ensure that none of the contents of the basket remained in the guiding catheter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The intervention was uneventful and the patient remained hemodynamically stable throughout the procedure&#46; The Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was withdrawn at the end of the procedure and the left femoral artery access site was transcutaneously closed with two ProGlide &#40;Abbott Vascular&#41; devices&#44; a suture-mediated closure system with threads made of non-resorbable 3-0 polypropylene&#46; Vascular closure of the right femoral artery was achieved with Angio-Seal&#8482; &#40;St&#46; Jude Medical&#41;&#44; a device that employs a collagen plug that not only physically closes the arteriotomy site but also induces platelet activation and aggregation when deployed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The patient was safely discharged from hospital two days later&#46; After eight months&#44; he reported class II angina according to Canadian Cardiovascular Society grading system and mild episodes of dyspnea on moderate effort&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0120" class="elsevierStylePara elsevierViewall">An 80-year-old male with type 2 diabetes&#44; hypertension&#44; dyslipidemia and a permanent pacemaker device implanted one year before due to complete heart block was transferred to our hospital with an acute myocardial infarction&#44; Killip class III&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">An electrocardiogram obtained immediately upon admission showed stable right ventricular pacing rhythm&#46; TTE showed a severely depressed LVEF &#40;34&#37;&#41; with global hypokinesis of the left ventricle&#46; There was no evidence of intracavitary thrombi&#46; Coronary angiogram revealed 70&#37; stenosis of the distal left main coronary artery &#40;LMCA&#41; &#40;Medina Classification 1&#44;0&#44;1&#41; and chronic total occlusions of the proximal LCX and middle RCA&#44; both partially perfused by collateral vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; The patient was rejected for CABG because of high operative risk and poor distal grafting targets&#46; After a Heart Team discussion&#44; it was decided to proceed with a PCI of the distal LMCA to the LAD with the support of a 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The procedure started with the insertion of a 6-Fr sheath into the right radial artery&#46; A contrast study of the aorta and both iliac arteries showed that the patient was a candidate for using the ventricular assist device&#46; A 14-Fr sheath was then inserted into the right femoral artery and&#44; after administration of 5000 units of UFH&#44; the 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was placed into the left ventricle&#44; as previously described&#46; The device was started&#44; with a maximum of 3&#46;0 l&#47;min of circulatory support necessary to maintain the patient hemodynamically stable during the procedure&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The ostium of the LMCA was catheterized using a 6-Fr Extra Back-Up 3&#46;5 guiding catheter &#40;Cardinal Health&#41; via right radial artery&#46; A Whisper &#40;Abbott Vascular&#41; guidewire was advanced into the LAD and multiple pre-dilation inflations were performed using a 2&#46;5&#215;8-mm Quantum&#8482; Maverick&#8482; balloon and a 3&#215;8-mm TREK balloon&#46; Then a 3&#46;5&#215;18-mm Onyx&#8482; &#40;Medtronic&#41; stent was successfully deployed in the distal LMCA towards the proximal LAD&#46; The stent was subsequently post-dilated with a 4&#46;0&#215;15-mm Quantum&#8482; Maverick&#8482; balloon at 20 atm&#44; with a good final angiographic result &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41;&#46; The patient remained hemodynamically stable throughout&#46; The Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was withdrawn and the sheath was removed at the end of the procedure&#46; The right femoral artery access site was closed using a ProGlide device&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The patient experienced a favorable clinical course and was discharged from hospital four days after the procedure&#46; Five months later&#44; he was free of chest pain and reported class II dyspnea according to the New York Heart Association Functional Classification&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">In this manuscript&#44; we presented two cases of high-risk PCI using the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46; In the setting of low coronary reserve&#44; severely depressed LV function and potential hemodynamic instability&#44; this device enabled hemodynamic stability to be maintained during the procedures without increasing vascular complications&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Author contributions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Sara Moura-Ferreira&#58; Drafted and designed the article&#59; acquired&#44; analyzed and interpreted data&#59; and approved the submitted and final versions&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Ricardo Ladeiras-Lopes&#58; Drafted and designed the article&#59; acquired&#44; analyzed and interpreted data&#59; and approved the submitted and final versions&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Domingas MBala&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Alberto Rodrigues&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Pedro Braga&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Vasco Gama&#58; Contributed to data collection and interpretation&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Case 1"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percutaneous coronary intervention &#40;PCI&#41; has been increasingly performed in patients with severely depressed left ventricular function and complex coronary lesions&#44; including multivessel disease&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mechanical ventricular assist devices play an increasingly important role in high-risk PCI&#46; Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; is a new percutaneous left ventricular assist device&#44; designed for short-term circulatory support&#46; It is a promising option for hemodynamic support in high-risk procedures and can potentially reduce PCI-related complications&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The authors present two case reports of high-risk PCI using the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the setting of low coronary flow reserve&#44; severely depressed left ventricular function and potential hemodynamic instability&#44; the Impella CP<span class="elsevierStyleSup">&#174;</span> device has made it possible to maintain hemodynamic stability during procedures&#44; without being associated with vascular complications&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As interven&#231;&#245;es coron&#225;rias percut&#226;neas &#40;ICP&#41; t&#234;m sido feitas com maior frequ&#234;ncia em doentes com depress&#227;o severa da fun&#231;&#227;o ventricular esquerda e com les&#245;es coron&#225;rias complexas&#44; inclusive doen&#231;a coron&#225;ria multivaso&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os dispositivos de assist&#234;ncia ventricular mec&#226;nica desempenham um papel cada vez mais importante nas ICP de elevado risco&#46; O Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; &#233; um novo dispositivo percut&#226;neo de assist&#234;ncia ventricular mec&#226;nica esquerda&#44; desenvolvido para apoio circulat&#243;rio de curta dura&#231;&#227;o&#46; Constitui uma op&#231;&#227;o prometedora de apoio hemodin&#226;mico em procedimentos de elevado risco&#44; com o potencial de reduzir as complica&#231;&#245;es relacionadas com as ICP&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam dois casos cl&#237;nicos de ICP de alto risco que usam o dispositivo Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No contexto de baixa reserva coron&#225;ria&#44; depress&#227;o severa da fun&#231;&#227;o do ventr&#237;culo esquerdo e de potencial instabilidade hemodin&#226;mica&#44; o Impella CP<span class="elsevierStyleSup">&#174;</span> permitiu manter a estabilidade hemodin&#226;mica dos doentes durante os procedimentos&#44; sem se associar a complica&#231;&#245;es vasculares&#46;</p></span>"
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                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">coronary artery bypass grafting</p>"
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                "termino" => "CMRI"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">cardiac magnetic resonance imaging</p>"
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                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">left ventricular ejection fraction</p>"
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                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">mechanical circulatory support</p>"
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                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">first obtuse marginal</p>"
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                "termino" => "PCI"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">percutaneous coronary intervention</p>"
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                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">right coronary artery</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; &#40;A&#41; The right anterior oblique caudal view reveals the saphenous vein graft &#40;SVG&#41; to the first obtuse marginal before intervention and the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46; &#40;B&#41; Distal embolic protection device&#44; Emboshield NAV &#40;Abbott Vascular&#41;&#44; deployed in the distal portion of the SVG&#46; &#40;C&#41; The right anterior oblique caudal view shows the final angiographic result&#46;</p>"
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                      "titulo" => "Trends in percutaneous coronary intervention from 2004 to 2013 according to the Portuguese National Registry of Interventional Cardiology"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Pereira"
                            1 => "R&#46;C&#46; Teles"
                            2 => "M&#46; Costa"
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                      "doi" => "10.1016/j.repc.2015.06.005"
                      "Revista" => array:6 [
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                        "fecha" => "2015"
                        "volumen" => "34"
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              "etiqueta" => "2"
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                    0 => array:2 [
                      "titulo" => "Stent for Life in Portugal&#58; this initiative is here to stay"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Pereira"
                            1 => "F&#46;J&#46; Pinto"
                            2 => "R&#46; Cale"
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                        ]
                      ]
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.repc.2014.02.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2014"
                        "volumen" => "33"
                        "paginaInicial" => "363"
                        "paginaFinal" => "370"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24998097"
                            "web" => "Medline"
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Case report
The role of Impella in high-risk percutaneous coronary intervention
O papel do Impella na intervenção coronária percutânea de alto risco
Sara Moura-Ferreiraa,1,
Autor para correspondência
sara.mouraferreira@gmail.com

Corresponding author.
, Ricardo Ladeiras-Lopesb,1, Domingas MBalab, Alberto Rodriguesb, Pedro Bragab, Vasco Gamab
a Cardiology Department, Hospital do Divino Espírito Santo, Ponta Delgada, Portugal
b Cardiology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; &#40;A&#41; The right anterior oblique caudal view reveals the saphenous vein graft &#40;SVG&#41; to the first obtuse marginal before intervention and the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46; &#40;B&#41; Distal embolic protection device&#44; Emboshield NAV &#40;Abbott Vascular&#41;&#44; deployed in the distal portion of the SVG&#46; &#40;C&#41; The right anterior oblique caudal view shows the final angiographic result&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewextended"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0075" class="elsevierStylePara elsevierViewall">Percutaneous coronary interventions &#40;PCIs&#41; have been increasingly performed for the treatment of stenotic coronary artery disease&#46; In Portugal alone&#44; the number of PCIs performed increased by 65&#37; in the decade from 2004 to 2013&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> Procedures have become more complex and challenging for the operator&#44; especially with high-risk patients deemed ineligible for surgical revascularization&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> There is no universally accepted definition for so-called &#8220;high-risk PCI&#8221;&#44; but the term covers the performance of a coronary intervention in high-risk coronary anatomy or in high-risk patients&#46; These patients often have low physiological reserve that may not withstand the deleterious effects of transient ischemia or hemodynamic instability&#44; nor the systemic impact of ischemia-reperfusion injury or no-reflow phenomena&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this setting&#44; the use of mechanical circulatory support &#40;MCS&#41; devices may help to avoid clinical deterioration by &#40;1&#41; increasing coronary and peripheral circulation and &#40;2&#41; unloading the myocardium&#44; thereby reducing its work and secondary ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The Impella<span class="elsevierStyleSup">&#174;</span> device &#40;Abiomed&#44; Inc&#46;&#41; is an MCS system that consists of a pump placed percutaneously across the aortic valve under fluoroscopic guidance&#46; It is connected to a console that enables external monitoring&#44; purging and control of the overall system&#46; In short&#44; Impella<span class="elsevierStyleSup">&#174;</span> aspirates blood from the left ventricle &#40;LV&#41; into the ascending aorta&#44; thereby unloading the LV&#44; increasing aortic and intracoronary pressure and reducing end-diastolic wall stress&#46; The end result is a favorable effect on the supply&#8211;demand equilibrium of the myocardium at risk&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> The PROTECT II<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> trial is the largest randomized trial comparing Impella<span class="elsevierStyleSup">&#174;</span> &#40;using Impella 2&#46;5<span class="elsevierStyleSup">&#174;</span>&#41; with an intraortic balloon counterpulsation to support nonemergent high-risk PCI&#46; The trial found no significant difference in major adverse events at discharge or 30 days&#44; but the per-protocol analysis revealed a strong trend toward decreased adverse events with Impella<span class="elsevierStyleSup">&#174;</span> at 90 days&#46; Therefore&#44; the use of Impella<span class="elsevierStyleSup">&#174;</span> during high-risk PCI may hold promise over the long term&#46; Notably&#44; in the Balloon Pump-Assisted Coronary Intervention Study&#44; an intraortic balloon counterpulsation pump failed to reduce major adverse cardiac and cardiovascular events in nonemergent high-risk PCI procedures compared to the conventional strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; is the new generation of the percutaneous&#44; catheter-based device that can provide a flow of up to 3&#46;5 l&#47;min&#46; Here&#44; we present two cases of high-risk PCI performed in our center with LV assistance provided by an Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0090" class="elsevierStylePara elsevierViewall">A 70-year-old diabetic male with a history of chronic kidney disease &#40;creatinine clearance 43 ml&#47;min&#41; was admitted to our cardiac intensive care unit with non-ST-elevation myocardial infarction&#44; Killip class III&#46; Thirty years previously&#44; he had undergone 3-vessel coronary artery bypass grafting &#40;CABG&#41; with saphenous vein grafts &#40;SVGs&#41; and had subsequently undergone PCI of the SVGs to the first obtuse marginal &#40;OM1&#41; in 2002 and 2009&#44; with implantation of a 4&#46;5&#215;13-mm Bx Velocity&#8482; stent &#40;Johnson &#38; Johnson&#41; and a 4&#46;0&#215;2&#46;8-mm Xience stent &#40;Abbott Vascular&#41;&#44; respectively&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On admission&#44; a transthoracic echocardiogram &#40;TTE&#41; showed severely depressed left ventricular ejection fraction &#40;LVEF&#41; &#40;estimated 29&#37;&#41;&#59; akinesis of the apex&#44; inferior wall&#44; middle and distal segments of the anterior wall&#59; and hypokinesis of the other walls&#46; There was no evidence of intracavitary thrombi&#46; Invasive coronary angiography revealed severe native coronary artery disease consisting of an occluded left anterior descending &#40;LAD&#41; artery at the origin and occluded left circumflex &#40;LCX&#41; and right coronary artery &#40;RCA&#41; in their middle segments&#46; The SVG to LAD was occluded&#44; the SVG to the OM1 had 90&#37; stenosis proximally &#40;pre-stent&#41; and the SVG to the right posterior descending artery had 70&#37; stenosis distally&#46; The patient underwent cardiac magnetic resonance imaging &#40;CMRI&#41;&#44; which showed extensive myocardial scarring involving the apex&#44; the inferior wall and the middle and distal segments of the anterior wall&#46; Finally&#44; an adenosine stress perfusion CMRI revealed ischemia of the basal segment of the inferolateral wall&#46; Based on this evidence&#44; and in an attempt to improve the patient&#39;s status&#44; it was decided to perform a PCI of the SVG to the OM1&#46; A 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was selected for support due to the low physiologic reserve of the patient and the relevance of the aforementioned graft in the perfusion of the remaining viable myocardium&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Following local anesthesia&#44; a 6-Fr sheath was inserted into the right femoral artery&#46; After performing a contrast study of the aorta and both iliac arteries&#44; the patient was considered a candidate for using the assist device&#46; A 14-Fr sheath was then placed in the left femoral artery&#46; After administration of 5000 units of unfractionated heparin &#40;UFH&#41;&#44; an angiographic pigtail diagnostic catheter &#40;Cardinal Health&#41; was used to deliver a specific 0&#46;14-inch guidewire to the LV&#46; The diagnostic catheter was then removed&#44; and the Impella CP<span class="elsevierStyleSup">&#174;</span> pump was advanced over the wire across the aortic valve under angiographic guidance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; The pump was started&#44; with a maximum of 3&#46;5 l per minute of circulatory support necessary to maintain the patient hemodynamically stable during the procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The SVG to the OM1 was intubated with a 6-Fr Amplatz Left 1 catheter &#40;Cardinal Health&#41;&#46; A distal embolic protection device&#44; the 6-Fr Emboshield NAV &#40;Abbott Vascular&#41;&#44; was gently passed into the SVG across the target lesion and was deployed at the distal portion of the graft &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; After pre-dilation of the target lesion with a 3&#46;5&#215;20-mm TREK balloon &#40;Abbott Vascular&#41;&#44; a 4&#46;0&#215;28-mm Xience stent was successfully deployed in the SVG&#46; Next&#44; the stent was post-dilated with a 4&#46;5&#215;15-mm Quantum&#8482; Maverick&#8482; balloon &#40;Boston Scientific&#41; at 18 atm&#46; The Emboshield NAV basket was then carefully withdrawn&#46; Aspiration was performed to clear the guide catheter of any debris and thrombi and ensure that none of the contents of the basket remained in the guiding catheter &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The intervention was uneventful and the patient remained hemodynamically stable throughout the procedure&#46; The Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was withdrawn at the end of the procedure and the left femoral artery access site was transcutaneously closed with two ProGlide &#40;Abbott Vascular&#41; devices&#44; a suture-mediated closure system with threads made of non-resorbable 3-0 polypropylene&#46; Vascular closure of the right femoral artery was achieved with Angio-Seal&#8482; &#40;St&#46; Jude Medical&#41;&#44; a device that employs a collagen plug that not only physically closes the arteriotomy site but also induces platelet activation and aggregation when deployed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The patient was safely discharged from hospital two days later&#46; After eight months&#44; he reported class II angina according to Canadian Cardiovascular Society grading system and mild episodes of dyspnea on moderate effort&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0120" class="elsevierStylePara elsevierViewall">An 80-year-old male with type 2 diabetes&#44; hypertension&#44; dyslipidemia and a permanent pacemaker device implanted one year before due to complete heart block was transferred to our hospital with an acute myocardial infarction&#44; Killip class III&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">An electrocardiogram obtained immediately upon admission showed stable right ventricular pacing rhythm&#46; TTE showed a severely depressed LVEF &#40;34&#37;&#41; with global hypokinesis of the left ventricle&#46; There was no evidence of intracavitary thrombi&#46; Coronary angiogram revealed 70&#37; stenosis of the distal left main coronary artery &#40;LMCA&#41; &#40;Medina Classification 1&#44;0&#44;1&#41; and chronic total occlusions of the proximal LCX and middle RCA&#44; both partially perfused by collateral vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; The patient was rejected for CABG because of high operative risk and poor distal grafting targets&#46; After a Heart Team discussion&#44; it was decided to proceed with a PCI of the distal LMCA to the LAD with the support of a 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The procedure started with the insertion of a 6-Fr sheath into the right radial artery&#46; A contrast study of the aorta and both iliac arteries showed that the patient was a candidate for using the ventricular assist device&#46; A 14-Fr sheath was then inserted into the right femoral artery and&#44; after administration of 5000 units of UFH&#44; the 4-l&#47;min Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was placed into the left ventricle&#44; as previously described&#46; The device was started&#44; with a maximum of 3&#46;0 l&#47;min of circulatory support necessary to maintain the patient hemodynamically stable during the procedure&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The ostium of the LMCA was catheterized using a 6-Fr Extra Back-Up 3&#46;5 guiding catheter &#40;Cardinal Health&#41; via right radial artery&#46; A Whisper &#40;Abbott Vascular&#41; guidewire was advanced into the LAD and multiple pre-dilation inflations were performed using a 2&#46;5&#215;8-mm Quantum&#8482; Maverick&#8482; balloon and a 3&#215;8-mm TREK balloon&#46; Then a 3&#46;5&#215;18-mm Onyx&#8482; &#40;Medtronic&#41; stent was successfully deployed in the distal LMCA towards the proximal LAD&#46; The stent was subsequently post-dilated with a 4&#46;0&#215;15-mm Quantum&#8482; Maverick&#8482; balloon at 20 atm&#44; with a good final angiographic result &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41;&#46; The patient remained hemodynamically stable throughout&#46; The Impella CP<span class="elsevierStyleSup">&#174;</span> assist device was withdrawn and the sheath was removed at the end of the procedure&#46; The right femoral artery access site was closed using a ProGlide device&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The patient experienced a favorable clinical course and was discharged from hospital four days after the procedure&#46; Five months later&#44; he was free of chest pain and reported class II dyspnea according to the New York Heart Association Functional Classification&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">In this manuscript&#44; we presented two cases of high-risk PCI using the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46; In the setting of low coronary reserve&#44; severely depressed LV function and potential hemodynamic instability&#44; this device enabled hemodynamic stability to be maintained during the procedures without increasing vascular complications&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Author contributions</span><p id="par0150" class="elsevierStylePara elsevierViewall">Sara Moura-Ferreira&#58; Drafted and designed the article&#59; acquired&#44; analyzed and interpreted data&#59; and approved the submitted and final versions&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Ricardo Ladeiras-Lopes&#58; Drafted and designed the article&#59; acquired&#44; analyzed and interpreted data&#59; and approved the submitted and final versions&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Domingas MBala&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Alberto Rodrigues&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Pedro Braga&#58; Performed a detailed analysis and interpretation of data&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Vasco Gama&#58; Contributed to data collection and interpretation&#59; provided a critical review of the article&#59; and approved the submitted and final versions&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percutaneous coronary intervention &#40;PCI&#41; has been increasingly performed in patients with severely depressed left ventricular function and complex coronary lesions&#44; including multivessel disease&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mechanical ventricular assist devices play an increasingly important role in high-risk PCI&#46; Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; is a new percutaneous left ventricular assist device&#44; designed for short-term circulatory support&#46; It is a promising option for hemodynamic support in high-risk procedures and can potentially reduce PCI-related complications&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The authors present two case reports of high-risk PCI using the Impella CP<span class="elsevierStyleSup">&#174;</span> device&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the setting of low coronary flow reserve&#44; severely depressed left ventricular function and potential hemodynamic instability&#44; the Impella CP<span class="elsevierStyleSup">&#174;</span> device has made it possible to maintain hemodynamic stability during procedures&#44; without being associated with vascular complications&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As interven&#231;&#245;es coron&#225;rias percut&#226;neas &#40;ICP&#41; t&#234;m sido feitas com maior frequ&#234;ncia em doentes com depress&#227;o severa da fun&#231;&#227;o ventricular esquerda e com les&#245;es coron&#225;rias complexas&#44; inclusive doen&#231;a coron&#225;ria multivaso&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os dispositivos de assist&#234;ncia ventricular mec&#226;nica desempenham um papel cada vez mais importante nas ICP de elevado risco&#46; O Impella CP<span class="elsevierStyleSup">&#174;</span> &#40;Abiomed&#44; Inc&#46;&#41; &#233; um novo dispositivo percut&#226;neo de assist&#234;ncia ventricular mec&#226;nica esquerda&#44; desenvolvido para apoio circulat&#243;rio de curta dura&#231;&#227;o&#46; Constitui uma op&#231;&#227;o prometedora de apoio hemodin&#226;mico em procedimentos de elevado risco&#44; com o potencial de reduzir as complica&#231;&#245;es relacionadas com as ICP&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam dois casos cl&#237;nicos de ICP de alto risco que usam o dispositivo Impella CP<span class="elsevierStyleSup">&#174;</span>&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No contexto de baixa reserva coron&#225;ria&#44; depress&#227;o severa da fun&#231;&#227;o do ventr&#237;culo esquerdo e de potencial instabilidade hemodin&#226;mica&#44; o Impella CP<span class="elsevierStyleSup">&#174;</span> permitiu manter a estabilidade hemodin&#226;mica dos doentes durante os procedimentos&#44; sem se associar a complica&#231;&#245;es vasculares&#46;</p></span>"
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                      "doi" => "10.1016/j.jcin.2014.07.030"
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