Case and Plan:
72-year-old obese female with crescendo angina and dyspnea was found to have severe AS on echo. A Cardiac Cath on April 9, 2024 revealed calcific 3V + LM CAD with large calcific nodule of distal left main, SYNTAX Score of 44 and EF 55%. Patient underwent CABG (LIMA for LAD, RIMA to Diagonal) and bioprosthetic SAVR and subsequently did well. Additional bypasses could not be done due to calcific aorta (‘Eggshell’). Patient continued to remain symptomatic with CCS Class II angina and DOE. Patient is now planned for imaging guided RotaTripsy DES intervention of residual large calcific nodule in distal LM/LCx.
Q&A
Q
In circumferential calcification, when will you not use a Rotablator?
A.
In small angulated vessels like 2.25-2.5mm Diagonals and OMs, even with circumferential calcium, RA use should be avoided for the fear of perforation. Yes if all other devices fails, then 1.25mm RA burr can be used cautiously as the last resort.
Q
Based on quadrant calcification, what is your strategy for debulking?
A.
My strategy for Ca+ modifying techniques is as follows;
- In 1-2 quadrant Ca+; Atherotomy using Wolverine or Scireflex/Angiosculpt
- In 3 quadrant Ca+; RA or IVL
- In 3-4 or 4 quadrant Ca+; OA is preferred but both RA or IVL are also effective. In many of these cases, more than 1 device strategy is needed for optimal plaque modification.
Q
Can you get an accurate estimate of the calcification by angiography alone - enough to clarify which debulking strategy to have?
A.
I am strongly of the opinion that angiography is very accurate in predicting severe calcification (>98% accuracy). It is the moderate calcification on angio, where predictive value of angiography goes down (about 80%), as many of these lesions are severely calcified on IV imaging. We demonstrated this observation in the MACE trial, in which operators were asked to grade the lesion calcification severity on angio and then compared to the core lab assessment.
Q
What is the incidence of side branch occlusion with Rotablator? Is it higher with larger burrs?
A.
Overall incidence of side branch occlusion with Rotablator is 4-5% vs 18-20% in non RA cases. We actually have not evaluated the relationship of RA burr size with SBr closure. I guess it will be more with smaller burrs due to their use in small vessels.
Q
In what cases will you not use IVL?
A.
Moderate calcium does not need IVL and also will be very cautions of using IVL in some cases of uLM lesions (or last remaining vessel) due to fear of 10-12 second ischemia during IVL balloon inflation causing significant CV collapse.
Q
Are there any cases in CAD, where the excimer laser is the device of choice?
A.
Excimer laser is the first device of choice in unexpanded ISR, uncrossable lesions and thrombotic calcified lesions.
Q
Which debulking device should you not use for a calcified nodule?
A.
All three devices, RA, OA and IVL will work good for Ca+ nodule, with OA having little edge over other 2. Excimer laser will not be effective in Ca+ nodules.
Q
Which has been your most significant publication this year?
A.
Most important publication from our group this year has been RotaCut trial which demistified the prevailing concept of device synergy to get better MSA. RotaCut trial showed that while CB is safe after RA, but dies not add any additional luminal gain vs NC balloon after RA.
Q
In what situation is the Dual Lumen support catheter really useful?
A.
In our opinion, duel lumen catheter is useful for distal delivery of vasodilators. We don’t use it for wiring the side branches, like some operators do.
Q
Are you doing any platelet assays? In which cases?
A.
Yes we do check PRU to assess for the clopidogrel resistance in some cases like stent thrombosis, recurrent PCIs. PRU value of 230 is our cutoff; higher value is reflection of clopidogrel resistance and if no bleeding issues, then we switch clopidogrel to Ticagrelor or Prasugrel.
