title: Elective or Emergency Use of Mechanical Circulatory Support Devices During Transcatheter Aortic Valve Replacement.
abstract: OBJECTIVE
  Evaluate the use of mechanical circulatory support (MCS) devices in high-risk patients undergoing transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  The use of MCS devices in elderly patients with multiple comorbidities undergoing TAVR is underexplored.
  
  
  METHODS
  All patients undergoing TAVR at a single tertiary academic center who required MCS during index procedure between 2008 and 2015 were included in a prospective database.
  
  
  RESULTS
  MCS was used in 9.4% (54/577) of all TAVRs (n = 52 Edwards Sapien and n = 2 CoreValves) of which 68.5% (n = 37) were used as part of a planned strategy, and 31.5% (n = 17) were used in emergency "bail-out" situations. IABP was the most commonly used device (87%) followed by Impella and ECMO (6% each). Among the MCS group, 22% required cardiopulmonary resuscitation during the procedure (n = 4 elective [11%] vs. n = 8 emergent [47%]) and 15% upgrade to a second device (Impella or CPB after IABP; n = 5 elective [14%] vs. n = 3 emergent [18%]). Median duration of support was 1-day. Device related complications were low (4%). In-hospital mortality in this extremely high-risk population was 24% (13/54) (11% [4/37] for elective cases and 53% [9/17] for emergency cases). Cardiogenic shock (50%) was the most common cause of in-hospital death. Cumulative all-cause 1-year mortality was 35% (19/54) (19% 97/370 for elective and 71% [12/17] for emergency cases).
  
  
  CONCLUSIONS
  Emergent use of MCS during TAVR in extremely high-risk population is associated with high short and long-term mortality rates. Early identification of patients at risk for hemodynamic compromise may rationalize elective utilization of MCS during TAVR.
authors.affiliation: Interventional Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Vikas
authors.initials: V
authors.lastname: Singh
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Abdulla A
authors.initials: AA
authors.lastname: Damluji
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Mendirichaga
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Alfonso
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Claudia A
authors.initials: CA
authors.lastname: Martinez
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Donald
authors.initials: D
authors.lastname: Williams
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Alan W
authors.initials: AW
authors.lastname: Heldman
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida.
authors.forename: Eduardo J
authors.initials: EJ
authors.lastname: de Marchena
authors.affiliation: Cardiovascular Division, Henry Ford Hospital, Detroit, Michigan.
authors.forename: William W
authors.initials: WW
authors.lastname: O'Neill
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Florida. mgcohen@med.miami.edu.
authors.forename: Mauricio G
authors.initials: MG
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000601:surgery*; D001243:Assisted Circulation / Q000295:instrumentation / Q000379:methods / Q000401:mortality; D002315:Cardiopulmonary Bypass / Q000295:instrumentation / Q000379:methods / Q000401:mortality; D017558:Elective Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000379:methods; D014481:United States / Q000453:epidemiology