62 year old male with recent onset CCS Class III angina with a positive SPECT MPI for inferior and anterior ischemia. A Cardiac Cath on May 2, 2017 revealed III Vessel CAD: 80% RCA-RPL1, 100% calcified proximal LAD with distal vessel filling via bridge collaterals, 90% calcified LCx OM2 bifurcation and SYNTAX score of 40.5. After Heart Team discussion, CABG was recommended, but declined. Patient underwent successful PCI of RCA branch RPL1 using Promus Premier DES. Now planned for multivessel staged PCI of CTO LAD and LCx OM2 using orbital atherectomy and DES with OCT guidance.
Moderator: Sameer Mehta, MD
I found the most educational and instructive case was severely angulated calcified subtotal circumflex which had a potential of causing coronary perforation. This case was done very cautiously after crossing the lesion with Fielder wire and then exchanged for the Rotawire and used 1.25mm burr very cautiously. All went very well and we highlighted various points in performing Rota in these extremely angulated heavily calcified lesions.
The case of Valve-in-Valve TAVR using Evolut R was very educational providing tips of accurate Supra annular deployment of the Evolut R Valve leading to minimal residual gradient.
J-CTO score is s simple and very useful tool in predicting procedural success as well rough time it will take for CTO lesion to cross. I usually ask the interventional fellows to calculate J-CTO score as part of pre-procedure discussion and analysis.
Yes, proximal blunt tip, which is the ambiguous proximal cap certainly is an adverse factor for CTO recanalizaion.
Both Rotational as well Orbital atherectomy can be used interchangeably in majority of calcified lesions. Hence yes, Rota could have also been used in today's case.
We have shown Rotational Atherectomy so many times in our live webcasts, hence, we wanted to teach the steps of performing Orbital Atherectomy (OA) correctly. That was simply the reason to use OA in the current case.
Orbital Atherectomy is simple to set up, simple to learn and all device parts & controls are on the table (field).
Orbital Atherectomy has the advantage of treating multiple lesions in a vessel by single burr by increasing the speed (80,000 to 120,000). Also, there is no need for temporary pacemaker with OA even during RCA or dominant Circumflex ablations. Our study of 20 cases with OCT have shown that in circumferential calcified lesions, Orbital Atherectomy makes deep cuts which results in better stent expansion compared to Rotablator.
Viper wire by its virtue of 0.012" size, is better steerable and can be advanced in the vessel in the majority of cases rather than exchanging with the workhorse wire which we usually do with Rota wire (which is 0.009" and is very flimsy). Also in some proximal lesions, Viper wire can also be used to deliver balloons and Stents post ablation, avoiding inserting another 0.014" wire.
Yes, we have seen some refractory slow flow even with Orbital Atherectomy but it certainly occurs less than with Rota. Treatment of slow flow remains the same with both devices; avoid hypotension, use vasodilators and in some cases IABP insertion for a few hours.
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.
53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017.
74 year old male with CKD Stage III presented with CCS Class II angina and positive stress MPI for moderate inferoapical ischemia.