Complex PCI of Calcified Tortuous RCA and Branches using Rotational Atherectomy and IVL – December 2021

Case and Plan:
65-year-old obese male, known CAD s/p PCI presented with severe CCS Class III angina. A Cardiac Cath on November 2, 2021 revealed 2 V CAD; calcified and tortuous multiple 70-80% RCA lesions, 90% LAD D2 with LVEF = 60%, SYNTAX Score of 17. Patient underwent successful intervention of LAD D2 using Promus Elite DES. Patient is now planned for complex PCI of calcified tortuous RCA and branches using rotational atherectomy and IVL.


Q Congratulations about session #150. What are you most proud of?
A. Of course doing uninterrupted 150 live cases and moderated by you, has been the greatest achievement of the ccclivecases. Additionally we are really proud of the consistent message we have created of performing PCI in accordance with Appropriate Use Criteria (AUC) of ACC and avoid any commercial bias's.
Q Is AUC your best academic contribution?
A. Absolutely ACC-AUC use in every case is one of the top contribution to the Interventional community and educating them how the cases should be done safely live.
Q Are you the biggest live case institution in the world?
A. Yes we have collectively done close to 900+ live cases as follows; CCCliveases= 300 cases, CCCsymposium since 1998= 450 cases, Live relays to India= 100 cases, Live relays to other centers= 50-55. This certainly will make us the biggest live cases institution in the world.
Q Are you planning to expand?
A. We will just continue to do what we are doing to educate the interventional cardiologists globally in the art of performing PCI safely, logically and with AUC accordance. We soon will be exploring additional opportunities of round the clock live case performance globally.
Q What factors contributed to the success of
A. Unbiased consistent practical teaching of techniques (tips and tricks) which have made Mount Sinai #1 in safety in NYS (NYS DOH reported outcomes) and in USA (ACC-NCDR reported outcomes) have enormously contributed to its success. We indeed a very big following with over 20,000+ hits monthly (coronary being average 12,000+).
Q What is the hardest aspect of ccclivecases?
A. Actually there is nothing hardest part of the ccclivecases now as whole cath lab machinery is in full swing to stage this monthly show. Yes appropriate case selection to emphasize the key aspects of technical learning, is vital and at times challenging.
Q Regarding today's case, would there be a need for a larger IVL balloon?
A. Yes IVL balloon to be effective, has to be 1:1 balloon-to-vessel size so that it is in contact with the lumen and deliver shocks effectively. Hence larger coronary IVL balloons of 4.5, 5, 5.5 and 6mm will be rarely needed.
Q What other areas could IVL develop?
A. Next frontier for IVL use will be unexpanded stents; these cases are always challenging, frustrating and sometimes impossible to expand despite ELCA or Rota.
Q When should you consider RotaTripsy?
A. Long diffuse severely calcified lesion in vessels >2.75mm will be most appropriate for RotaTripsy; use small Rota burr of 1.5mm followed by 1:1 size IVL balloon in these cases. This device synergy has a promise to reduce Rota complications as well will allow effective delivery of IVL balloon.
Q What is the response of your surgeons to FAME 3?
A. Actually CT surgeons have been unusually quiet about the results of the FAME-3 trial. At present, focus has shifted to angiographic lesion severity for interventions and reserve FFR for borderline angiographic lesions of 50-70%.


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