Q&A
Q.
Please provide more rationale for using a 1.75 burr in this case?
A.
Actually 1.75mm burr was the right size as vessel size was 3.25mm+; making it 0.55 B:A ratio. It is safe and appropriate as it is <0.6 recommended.
Q.
Would a 1.50 burr not be a safer option considering that additional ablative therapy would be required?
A.
Yes 1.5mm burr can also be used as in about 1/3rd calcified lesions will also use IVL after RA (RotaTripsy).
Q.
Are you universally using imaging to determine the size of IVL devices?
A.
Yes, use of imaging to decide the IVL catheter size, is a good interventional practice to get the best results.
Q.
Is IVUS adequate for this?
A.
Yes IVUS is appropriate to size the IVL and OCT may be used too.
Q.
In which cases do you feel RotaTripsy should be the first line?
A.
Large vessels (3.5mm +) with severe calcium, is best suited for RotaTripsy (1.75mm burr followed by 3.5/4mm IVL). This strategy usually leads to good stent expansion in these challenging large calcified vessels.
Q.
Are you always sizing IVL devices 1:1?
A.
Yes to have best effect of IVL therapy, it should be sized to 1:1 to vessel size. Usually balloon inflation pressure is 4-6 but can go up to 6-8: not more.
Q.
Would you undersize IVL in tapering vessels, in tortuosity and in bifurcations?
A.
I will recommend IVL Catheter size to be the mean of prox and distal vessel, erring on the quarter size higher for the closest size.
Q.
The LCX in bifurcating LMCA has been poorly understood and managed?
A.
Agree that LCx ostium remains the Achilles heal of LM bifurcation PCI in terms of lower final MSA and subsequent high restenosis. Various mechanism like angulation, carina shift and elastic recoil have been suggested. But there is no clear valid explanation of this adversity.
Q.
Which would be the next LVAD to gain approval?
A.
Kardian, is a 14Fr Impella like LVAD and is expected to get approval by Q1, 2025. RCT has started and I am the national PI for it along with Bill Nicholas.
Q.
Cost of LVAD in 3 years?
A.
I expect the cost of LVAD to go down significantly with 3-4 devices getting FDA approval in next 2 years; from current $25K to about $15-18K. Also they all will be 9Fr from current 14Fr cannula and will have increased ease of use along with lower vascular complications.
