77 year old male with known chronic systolic heart failure presented with new onset CCS Class III angina and a positive stress MPI. A Cardiac Cath on May 11, 2017 revealed III Vessel CAD: 100% calcified proximal RCA, 95% LAD-D1 bifurcation, 100% calcified proximal LCx and SYNTAX score of 54.5 with severe LV dysfunction, EF 20%. Cardiac MRI showed viability in all three coronary territories. After Heart Team discussion, CABG was recommended, but declined by CT surgeon due to severe biventricular dysfunction. Now planned for complex high-risk protected PCI of RCA CTO and/or LAD/D1 lesions with Impella LV support.
Moderator: Sameer Mehta, MD
In my opinion, annual PCI volume per operator should be 50 cases per year rather then currently recommended 75/yr.
For the Hospital, annual volume should be a minimum of 400 PCIs per year. Numerous publications have supported this recommendation.
For NY State 85% of the operators have annual PCI volume above 50 (approx 610 Interventionalists) and 65 of the 68 cath labs have PCI volume over 400 annually.
Actually, both for NY state as well as for NCDR, only one Interventionalist gets the credit for PCI; no credit to the assistant or secondary operator.
Actually, it is on the contrary, that low volume operators and hospitals have better outcomes, largely mediated by lower D2B time and lower symptom onset to balloon time driven largely by the proximity of the local institutions. NY State data have confirmed this finding.
I agree that a small stent gap left at the Diagonal ostium due to extreme angulation is troublesome and will predispose for higher restenosis. But based on the complexity of the case and time taken to perform the PCI, we decided not to put in an additional stent. This pt will be followed closely for any MACE and also for early restenosis by stress MPI in 6 months or a follow-up cath in 6-9 months.
That is correct and if restenosis occurs in this type of complex case, it is always easy to treat.
Actually, the most commonly used Supercross in our lab is 120 (2/3rd time) and 90 in other 1/3rd cases. Because many of the 90% angulated side branches can be wired with hydrophilic wires (Fielder, Pilot or Marvel) after some manipulations.
I actually liked the Monorail Venture catheter better and it is easier to use but it has been taken off the market.
New Impella innovations have been; wireless insertion, Impella CP, Right sided Impella Axillary Impella and now newer designs of lower sheath size to 9-10Fr.
71 year old male with multiple CAD risk factors presented with NSTEMI, pneumonia and septic shock in October 2018.
57 year old diabetic male presented with new onset CCS Class II angina and positive stress echo for multisegmental wall hypokinesis.
86 year old female with chronic stable angina CCS Class II and positive MPI for two years being managed on medication.
62 year old male presented with CCS Class II angina and positive SPECT MPI for basal inferior and inferolateral moderate size area of ischemia and infarction.