Complex PCI of Calcified RCA via Evolut TAVR – September 2021

Case and Plan:
75-year-old female with prior CABG presented with new onset angina and progressive NYHA Class III heart failure for last 6 months. Echo revealed severe AS with planned TAVR. A cardiac cath on July 27, 2021 at time of TAVR procedure revealed patent LIMA to LAD, patent SVG to OM1 and multiple 90% severe calcified RCA lesions. Patient underwent TF-TAVR using a 29mm Evolut Pro+ valve via right percutaneous femoral access with Shockwave lithotripsy of right iliac artery. Patient is now planned for complex PCI of calcified RCA via Evolut TAVR valve struts using rotational atherectomy + IVL (RotaTripsy) and DES.

Q&A

Q Regarding RotaTripsy, does it not make sense to have 1.5 burr as the default catheter?
A. I agree that 1.5mm Rota burr followed by 1:1 size shockwave balloon will be the best strategy in the future to tackle the calcified coronary lesions; Scientic rationale of RotaTripsy.
Q Have you ever needed a temporary pacemaker for IVL?
A. Temporary pacemaker is not needed for IVL and it has not been required in our cases so far at Sinai.
Q Ever had any incidence of VF with IVL?
A. No Vfib during IVL so far but we have seen ventricular dependence and pacing few times in our cases. This phenomenon also has been reported in the IVL trials. There were no clinical sequelae of this clinical phenomenon.
Q With the ascent of IVL, what would be the indication of Orbital Atherectomy?
A. In my opinion, only Rotational Atherectomy and IVL will remain after few years in the calcium management and Orbital Atherectomy use will be minimized or even disappear.
Q Regarding accessing coronaries with TAVR, soft-tip, atraumatic guiders with ample use of guide extension catheters?
A. During coronary access post TAVR, we always need to be cognizant of not damaging the TAVR struts and leaflets. Hence soft tip guide catheters such as Mach-1 of BSC with frequent use of Gide extenders, should be practiced.
Q Ever had access issues with Edwards device?
A. Rare cases of engaging LM after Sapien valve has been reported but we never had trouble in coronary engagement post Sapien TAVR at Sinai.
Q Rare cases of engaging LM after Sapien valve has been reported but we never had trouble in coronary engagement post Sapien TAVR at Sinai.
A. IVL Balloon ruptured in our case, occurred likely due to calcium spicule even post small Rota and 2 cycles of IVL shocks.
Q Can such a balloon rupture cause perforations?
A. Yes any balloon rupture increases the chances of coronary perforation as dye jet comes out under pressure from the ruptured pinhole. Balloon ruptured also commonly causes the coronary dissections and in sone cases slow flow due to localized air embolism.
Q What seems to be the benefits of the newly approved Portico device?
A. Newly approved Portico device does not have any clear advantage (hemodynamics , performance, 1-yr outcomes or durability) over currently FDA approved TAVR valves, except it’s lowest cost. That is how it is being marketed out of USA.
Q For the lone case you mentioned where PCI of the TAVR device failed due to access, how did you manage the case?
A. Our 87 yrs old pt where we could not engage the diseased LM post CoreValve TAVR despite 2 separate attempts and CT guidance, CT surgeon also declined the surgery due to high STS risk and frailty and pt was managed medically. Pt ultimately died after few months; natural history of LM disease.

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