Complex coronary cases
High Risk PCI of Calcific LM Bifurcation with Rotational Atherectomy and Impella LV Assist – Nov 2015

86 year-old male with chronic ischemic heart diease, prior MI and PCI in the remote past, presented with crescendo CCS Class III angina and chronic systolic heart failure. A stress MPI revealed large severe inferior wall defect with significant reperfusion. A Cardiac Cath on September 28, 2015 revealed multivessel calcific CAD; 80% distal LM bifurcation, 60% mid LAD and 80% D1, 95% LCx – LPL1 and CTO of LPDA with moderate-severe systolic LV dysfunction (LVEF 30%) and SYNTAX score of 39. After Heart Team discussion CABG was recommended, but patient refused any revascularization and went home. He continued to be symptomatic on maximal tolerable medical therapy. Patient is now planned for high risk PCI of calcific left main bifurcation with rotational atherecomy and Impella LV assist.

1:49:43

Q&A
Q
After Impella would not deliver, why not try IABP?
A.

Yes IABP insertion could have been another reasonable choice.


Q
When was Impella sheath removed??
A.

After the end of the case, Impella sheath was removed by 2 precloses.


Q
What contributed to inability to deliver Impella delivery - calcification, tortousity or both?
A.

Both tortuosity and calcification along with moderate lesion in the angulated Rt Common Iliac artery. After the initial passage of Impella, the second attempt failure probably was contributed by mild dissection also.


Q
This must have been a rare case of non-deliverability of Impella?
A.

That is correct as Impella delivery failure rate is <2%.


Q
What are follow up plans for this elderly patient?
A.

Pt will be discharged after 24Hrs and after that he will be followed clinically. If remains asymptomatic, then stress MPI after 8-9 mths will be advised.


Q
Do you feel incorporation of the Heart Team contributes significantly in decreasing inappropriate procedures?
A.

Yes as Heart team discussion gives various possible options to the complex CAD pts. Also it gives time to get all caregivers to get involved including additional family members in these complex CAD Pts.


Q
Inappropriate PCI is the low hanging fruit of PCI - the real challenge will be to reduce Uncertain procedures? Would you agree?
A.

I will say that once you focus on Appropriate PCI category, Uncertain category PCI will automatically come down.


Q
Would Fame 3 be a further assault on PCI volumes?
A.

In my opinion, FAME 3 trial may show equality of PCI to CABG by reducing the stent numbers. This will be the first trial to show the equality if true.


Q
In what percentage of cases do you perform FFR?
A.

Approximately 60% of mine non-acute and non-CABG PCIs are done with FFR.


Q
And of those, in what percentage does FFR alter your pre-PCI strategy?
A.

Almost in 1/3rd of cases FFR changes the PCI need.


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