62 year old male with recent onset CCS Class III angina with a positive SPECT MPI for inferior and anterior ischemia. A Cardiac Cath on May 2, 2017 revealed III Vessel CAD: 80% RCA-RPL1, 100% calcified proximal LAD with distal vessel filling via bridge collaterals, 90% calcified LCx OM2 bifurcation and SYNTAX score of 40.5. After Heart Team discussion, CABG was recommended, but declined. Patient underwent successful PCI of RCA branch RPL1 using Promus Premier DES. Now planned for multivessel staged PCI of CTO LAD and LCx OM2 using orbital atherectomy and DES with OCT guidance.
Moderator: Sameer Mehta, MD
Q&A
Q
In reviewing your conference coronary live cases, which of the live cases did you find most instructive?
A.
I found the most educational and instructive case was severely angulated calcified subtotal circumflex which had a potential of causing coronary perforation. This case was done very cautiously after crossing the lesion with Fielder wire and then exchanged for the Rotawire and used 1.25mm burr very cautiously. All went very well and we highlighted various points in performing Rota in these extremely angulated heavily calcified lesions.
Q
And among Structural Heart Disease?
A.
The case of Valve-in-Valve TAVR using Evolut R was very educational providing tips of accurate Supra annular deployment of the Evolut R Valve leading to minimal residual gradient.
Q
While teaching your students, which CTO score do you emphasize?
A.
J-CTO score is s simple and very useful tool in predicting procedural success as well rough time it will take for CTO lesion to cross. I usually ask the interventional fellows to calculate J-CTO score as part of pre-procedure discussion and analysis.
Q
Is the Ellis Proximal Cap Ambiguity a useful practical tool?
A.
Yes, proximal blunt tip, which is the ambiguous proximal cap certainly is an adverse factor for CTO recanalizaion.
Q
Should today's case have been performed with Rotablator?
A.
Both Rotational as well Orbital atherectomy can be used interchangeably in majority of calcified lesions. Hence yes, Rota could have also been used in today's case.
Q
What made you select Orbital Atherectomy?
A.
We have shown Rotational Atherectomy so many times in our live webcasts, hence, we wanted to teach the steps of performing Orbital Atherectomy (OA) correctly. That was simply the reason to use OA in the current case.
Q
In which aspect is Orbital Atherectomy simpler than Rotational Atherectomy?
A.
Orbital Atherectomy is simple to set up, simple to learn and all device parts & controls are on the table (field).
Q
Besides the degree of calcification (less for Orbital) and relative simplicity of use, can you define some indications where Orbital Atherectomy is more effective than Rotational Atherectomy?
A.
Orbital Atherectomy has the advantage of treating multiple lesions in a vessel by single burr by increasing the speed (80,000 to 120,000). Also, there is no need for temporary pacemaker with OA even during RCA or dominant Circumflex ablations. Our study of 20 cases with OCT have shown that in circumferential calcified lesions, Orbital Atherectomy makes deep cuts which results in better stent expansion compared to Rotablator.
Q
How do you find the specialty guide wires for Orbital Atherectomy in comparison to Rotablator wire?
A.
Viper wire by its virtue of 0.012" size, is better steerable and can be advanced in the vessel in the majority of cases rather than exchanging with the workhorse wire which we usually do with Rota wire (which is 0.009" and is very flimsy). Also in some proximal lesions, Viper wire can also be used to deliver balloons and Stents post ablation, avoiding inserting another 0.014" wire.
Q
Have you had any cases of stubborn no reflow with Orbital Atherectomy?
A.
Yes, we have seen some refractory slow flow even with Orbital Atherectomy but it certainly occurs less than with Rota. Treatment of slow flow remains the same with both devices; avoid hypotension, use vasodilators and in some cases IABP insertion for a few hours.
Excellent you are doing a great job