This article describes how the interventional cardiology team handles high-risk patients in the cath lab, from procedural preparation and planning through procedural monitoring, as well as weaning strategies and access site management.

Before high-risk Protected PCI, the cardiac team should discuss the case and outline the treatment strategy as well as perform baseline blood laboratory tests. During the procedure, continuous monitoring of vital signs and ECG is important so that the team can react immediately if any adverse situations arise. Other procedural considerations discussed include anticoagulation, micropuncture and use of ultrasound and fluoroscopy for vascular access, hemodynamic monitoring, and preparation for emergent situations such as respiratory decompensation or need for surgical intervention.

The authors also discuss the use of transthoracic echocardiography (TTE) before and during the procedure, the benefits gained with right heart catheterization (RHC), the importance of monitoring arterial pressure, and blood chemistry analysis before and during the procedure. During the procedure it is important to watch for left heart failure and right heart failure. The authors discuss the advantages of using Impella CP with SmartAssist heart pump to detect hemodynamic changes and when to consider escalation of LV support. They also explain that with continuous measurement of pulmonary and right atrial pressures, pulmonary artery pulsatility index (PAPi) may help detect early right heart failure.

Regarding weaning strategies, the authors recommend that the Impella heart pump should be removed in the cath lab at the end of a Protected PCI case unless the patient is hemodynamically unstable, in which case the patient should be transferred to the cardiac critical care unit with Impella support. The authors discuss both non-invasive and invasive access site closure strategies and state that patient characteristics and cardiology team experience should determine the appropriate strategy.