Protected PCI of Calcified LAD via Orbital Atherectomy – June 2019

73 year old male with extensive PAD, s/P PTA presented with CCS Class II angina and high risk positive SPECT MPI for anterior and inferior ischemia done as the part of the pre-op evaluation for lower limb vascular surgery. A Cardiac Cath on April 10, 2019 revealed II Vessel CAD: 100% prox RCA fills via collaterals for LCx, 80-90% calcified angulated lesion of prox-mid LAD with SYNTAX Score of 23, severe LV dysfunction and LVEF 30%. Patient is now planned for Protected PCI of complex calcified LAD using orbital atherectomy and DES with LV Impella assist.

Moderator: Sameer Mehta, MD



Q What single aspect is most satisfying to you on this 10th anniversary of your webcast?
A. Increasing audience and followers of the educational mission we started 10 years ago, is the most satisfying aspect of the ccclivewebcast journey. We never imagined that there will be consistent 10,000+ views per month globally; that in fact is the reality now.
Q How can we best utilize the apps?
A. Apps technology use will increase with proper advertisement as well as practical demonstration during the live cases, showing its utility.
Q How many apps are there?
A. Presently 5 Apps made by Dr Kini in collaboration with Mount Sinai are available for download and instant use free of charge. These are; BifurcAID, OCTAID, TranseptAID, CathAID and most recently launched CalcificAID. All these App names are self explanatory of their specific uses.
Q Are they made by professionals?
A. Yes all these Apps are made by the professional (some from India and some from USA) in conjunction with Icahn School of Medicine Technology and Innovation branch.
Q Which version is best to teach our fellows - we are at a non-academic institution but have rotating students and fellows. The long or short format?
A. For the learning point of view, full version of the CCClivewebcast will give the best results and is most productive. The 20-minutes abbreviated version is ideal for the practicing Interventionlists who just want to know the intricate procedural steps and details of that particular intervention.
Q Are you planning any changes to your format?
A. We do not plan to any major change to the format of CCClivewebast and keep the same sequence of eblast, case presentation, cine review, didactic lecture, then performance of the case followed by Takehome message and final Q&A. Having said that, we will implement following minor modifications to make the webcast more upto date; 1) Eblast of the case now will have the videoclip also in addition to the still frame of the coronary anatomy 2) Will shorten the case history presentation to one page utilizing just the key bullet points and 3) Will increase Q&A numbers to 5 from current 3.
Q In today's case, why did you not use a Rotablator?
A. Yes, this calcific non-tortuous LAD was suitable for both Rota as well as OA and could have been interchanged. We have shown RA performance in our numerous webcasts (>60+) but OA has been shown only 5 times. There have been requests to show more OAs in the future to appropriately teach its use in the calcific lesions. Hence we will now try to alternate both these ablative technologies in calcified lesions going forward.
Q Could today's case not have been done without Impella?
A. Yes, Impella use is appropriate in today’s case despite having near normal LVEF, due to lesion complexity and CT surgery turn down. One important reason for not using Impella in today’s case would have been the presence of PAD. But yes today’s case could have also been done safely without Impella or may be with IABP support only.
Q In India, the cost of Impella is too high? How to approach this case then?
A. Impella’s current cost being Rs 15Laks, has limited its use even in appropriately indicated cases of complex CAD and EF <30%. Reduced Impella cost in the future by some govt scheme or invention of a LV support device by an Indian company will be the answer in future.
Q We have no atherectomy device. Should we do this case with high pressure balloons or refer it to another center?
A. This lesion being heavily calcified will have best results of stent expansion/apposition after Atherectomy (OA or RA) rather then lesion modification by NC balloon or cutting balloon. If no atherectomy is available, then case could first be tried by non-atherectomy technique and if lesion opens up well, then stenting will be appropriate. In that case final IVUS/ OCT should be done to confirm full stent expansion and apposition.


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