High Risk PCI of ComplexLM/LAD-D1 using RA with Impella Assist

Case and Plan:
90-year-old male presented with CCS Class III angina and moderate interior, apical and anteroseptal ischemia. Cath @ OSH revealed calcified 3V + LM CAD (refused CABG). A Cardiac Cath on May 31, 2022 revealed 3 V + LM CAD: 80% RCA, 60% LM with multiple 95% proximal LAD/D1 lesions with SYNTAX Score of 57 and LVEF of 28%. Patient underwent successful intervention of RCA using RA + IVL and 3 Xience DES. Patient is now planned for high risk staged PCI of complex LM/LAD-D1 bifurcation using rotational atherectomy and mini-crush technique with Impella device.

Q&A

Q Regarding gender, what steps do you take at your institution to improve outcomes for women?
A. Actually two important aspect I see in the gender and cardiac care issues; reluctant to get medical care and improper diagnosis due to atypical symptoms. The first part of access to medical care is being tackled by our various community outreach activities. Second part of indicated testing to make the proper diagnosis is being done by educating our residents, fellows and junior attendings.
Q Do cardiac surgeons also have strategies in place?
A. Cardiac surgeon's usually do not encounter this gender issue in diagnosis as it is a medical issue but yes female gender has higher perioperative, inhospital and short-term mortality and morbidity after any type of cardiac surgery compared to their male counterpart.
Q Are you using similar access rates for both men and women?
A. Yes our radial access is similar in both sexes around 50-52% with slightly higher crossover to femoral access due to spasm or tortuousity; 5% in female vs 3% in males.
Q Are there outreach programs at your institution for reducing gender gaps in interventional cardiology?
A. That is correct that Sinai has implemented numerous outreach programs to reduce this gap in access care especially designed for women and conducted preferentially by female staff and MDs.
Q Are Fielder and Finecross your first default strategy for approaching most complex lesions?
A. Yes Fielder guide wire and Finecross microcatheter are our number one work horse equipments for tackling complex cases.
Q In today's case, will you bring the patient back for reviewing the LMCA and the ostial LCX?
A. Today's case had successful PCI of LM and LAD with still significant residual LCx disease. In this pt due to her advance age (90+yrs), we plan to manage it conservatively. If she remains symptomatic, then only we will bring her for LCx PCI.
Q How much is the SYNTAX score post today's intervention?
A. In thus pt, rSS now is 12; still significant due to residual LCx lesions. rSS >8 in earlier studies have been associated with higher MACE; but this may not be true in this 90yr old female.
Q How does the reduced SYNTAX score affect future management for this patient?
A. Overall this Pt now has well revascularized RCA, LM, LAD and diagonals. This will certainly reduce her major morbidity and mortality. Residual LCx disease may continue to cause some angina and dyspnea symptoms; which could be managed medically.
Q Why is the enrollment of PROTECT relatively slow?
A. Protect IV trial is a complex trial including complex MV or LM CAD and LVEF <40% (as assessed by the core lab) with no prior PCI in last 1 year and expected survival of minimum 2 years. After documenting proper vascular access, pts are randomized to Impella CP vs standard of care which can include IABP. There is no crossover allowed. Intervention needs to target towards complete revascularization. These all criteria making difficulty in enrollment in the trial.
Q Are there other left ventricular support devices on the horizon
A. Actually there are at-least 3 LV support devices in making but none has gone beyond the bench and animal testing. LV support device manufactured by CSI has just completed FIM series of 5 cases.

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