Complex coronary cases
Protected LM and LCx DES PCI through CoreValve struts using Guideliner and Rotational Atherectomy – April 2017

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81 year old male with known CAD, prior CABG (2006) and CoreValve TAVR (Jan 2015) now presented with crescendo exertional angina despite optimal medical therapy. A pharmacological MPI revealed moderate to severe lateral and inferolateral ischemia. Patient had known jeopardized calcified 90% left main and 80% circumflex disease pre-TAVR with occluded aortic anastomosis of diagonal and OM vein graft with patent jump segment. Patient continues to have Class III angina despite maximal anti-ischemic therapy. Now planned for protected left main and circumflex DES PCI through CoreValve struts using Guideliner and Rotational Atherectomy.


Are you able to predict the long term results from MACE?

MACE trial essentially showed that only severely calcified lesions (not mild or moderately calcified) have higher periprocedural MI, angiographic dissections and higher subsequent MI and TVR at one year. I predict that these MACE rates will continue to separate on subsequent years also.

The message from MACE is powerful - are you planning a solid manuscript with long-term results, discussions about importance of lesion modification and recommendations on tips and tricks with Rotablator.

There is a caveat about the MACE results; that yes severely calcified lesions (n= 114) have poor short and long term outcomes but we still do not know that 32% of these cases who underwent Rotational atherectomy (RA) have different (better) outcomes. These data are being analyzed and will be the part of the final manuscript. I hope, if positive in favor of RA, then we will have a clear and effective message; which so far has been lacking in any of the old or new RA trials.

Has ECLIPSE proceeded beyond a stage where Rotational Ablation cannot be added? Is that a result of sponsorship that separates competing technologies?

Yes ECLIPSE trial has started enrolling pts and RA is excluded largely because of no clear indications from other trials that RA improves long term outcome; which is the main primary outcome of the Eclipse trial.

Should guidelines provide recommendations for the calcified lesion substrate as this requires a different approach?

ACC Guidelines puts atherectony as the Class IIa indication for undilatable and calcified lesions. Calcified lesion is still not the Major Comorbidity Condition (MCC) yet for DRG but Atherectomy has separate added reimbursement; that takes care of the added equipment and hospital cost for these calcified lesions.

In 2017, what percentage of severe calcifications should be treated with Rotablation (assuming this practice is >80% at your institution)?

In my opinion optimal number to use atherectomy in severely calcified lesions should be in 60-70% cases (it is 32% now in US as per MACE trial); remainder may be well treated by NC balloons especially with associated thrombotic lesions and diffusely calcified lesion in small vessels in 2-2.25mm vessels.

Brilliant case today, including your decision to not deal with LCX. What were the deciding features for this success?

Today's case was very tricky and complex because of going thru the struts of the CoreValve, poor guide support and severely calcified angulated distal LM/LAD lesion. Persistence, technical expertise in RA and our prior experience in these scenario, made today's case successful. Hopeful tricks and tips we provided today will help our viewer interventionalists to tackle these cases in their practice; which will be increasingly encountered in future.

Should it be mandatory to perform PCI prior to TAVR?

Yes as per the ACC/AHA council recommendation in the Nov 2016 document, coronary angiography should be routine pre TAVR and also to do PCI in cases of significant obstructive lesion in large epicardial vessel supplying significant myocardium irrespective of stress test or any physiological assessment.

Should this decision be guided by angiography or FFR or by symptoms?

Coronay angiography should be routine and then PCI to be guided usually by visual estimation (>80%) or in equivocal cases by IVUS. FFR or stress test may be risky in these pts. iFR may become an alternate physiological assessment in these angiographic intermediate cases.

Have you ever had a TAVR patient go for CABG?

Since majority of our TAVR cases are high or extreme surgical risk cases, none of our TAVR pts have gone for CABG post TAVR; we have done PCI in 28 TAVR cases so fa, one case even 3 times (n= 900+). I am sure we may encounter cases in future who will require CABG post TAVR especially for recurrent ISR or unsuccessful PCI.

Any precautions using Rotablator through TAVR struts?

Main precaution being is to avoid ablating the TAVR valve struts by RA; hence guide catheter or guideliner should extend beyond the valve struts into the coronary ostia.


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One thought on “Protected LM and LCx DES PCI through CoreValve struts using Guideliner and Rotational Atherectomy – April 2017”

  1. c gasperetti md says:

    a beautiful case and discussion; thank you

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