High Risk PCI of LAD/D1/D2 using Rotational Atherectomy and DES with Impella LV Assist – Nov 2011

72-year old female with progressive dyspnea and crescendo angina presented on October 14, 2011. Cardiac Cath revealed mild pulmonary hypertension, minimal Aortic Stenosis, II vessel CAD (RCA and LAD) and LVEF 25%. Patient underwent PCI of RCA using Xience V DES. Now planned for high risk PCI of complex calcified bifurcation LAD/D1/D2 lesions using Rotational Atherectomy and DES with Impella LV Assist Device.

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Q&A

Q Would FFR provide additional information in this case?
A. It supplements the angio information.
Q The LAD is a technically more challenging lesion while the RCA was probably more severe – how do you choose between the two as the first to approach? One approach would seek doing the technically harder lesion first?
A. We always try to do the simpler lesion first along with diagnostic cath and the difficult lesion as staged procedure after few weeks.
Q What is the status of TAVI at Mt. Sinai Hospital?
A. We are one of the top 10 TAVI enrollment site of the CoreValve TAVI trial and program is doing well.
Q How much has the Impella device improved since you first began using it?
A. Most important advances have been the Quick set up and new automated clearly readable console.
Q What is constraining its wider use?
A. Vasular access as it requires 13Frs sheath vs 7.5Fr for IABP.
Q There is a perception that the device is too expensive? That its reimbursement is challenging? That these may be reasons for its limited use in some parts of the world?
A. Yes Impella catheter cost $20K vs $800 for IABP. But Impella is classified as the LVAD and hence higher DRG takes care of the high cost and hospital does not loose money.
Q What is the single unequivocal reason where the Impella catheter is genuinely irreplaceable?
A. Pt with LVEF <20% and has complex 3 V or LM disease; In this pt I will make every effort to use Impella to imptove the procedural outcomes and avoid any catastrophy.
Q What works better for no reflow with Rotational Ablation in similarly impaired LV function – IABP or Impella?
A. Clearly Impella better then IABP in this situation.
Q What anti-coagulation strategy do you employ with the Impella?
A. Bivalirudin and making sure that ACT is >300 sec before Impella is inserted.
Q Have results of the Impella clinical trials met with your expectations?
A. Yes at the 90-day mark. The disappointment has been in the Rota group as this group had unexpected higher CK-MB elevations.

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