PCI of Complex Tortuous RCA Lesions with Impella LV Assist – Oct 2012

Case: 73 year old male with III vessel CAD, status post CABG x3 (LIMA—LAD, Radial—D1 and SVG—OM) presented on 9/17/2012 with small NSTEMI. Patient underwent DES of native LCx‐OM1 and DES of Radial graft to D1. LVEF 30%. Now planned for PCI of complex tortuous RCA Lesions with Impella LV Assist Device.



Q Why are you preferring the Impella catheter in this procedure?
A. This case had very high chance of transient closure during PCI due to tortuosity and hence needed LV support at that critical time. Indeed there was transient closure of RCA during PCI due to pseudo lesions and despite that, we were able to perform excellent PCI, largely due to LV support during that critical time. Hence many times we need to predict the potential common procedural complications in complex PCIs and have to be prepared for them.
Q Did you contemplate Impella for the previous procedure on this patient?
A. NO as previous PCI was a simple LAD/Diagonal bifurcation, with quick excellent angiographic results.
Q Please enumerate the changes in the new Impella device?
A. Few are; Quick ready setup, new peel away 13Fr sheath, red introducer to load the wire retrograde, simple to understand monitor display and new Impella CP providing 4L/min of cardiac output.
Q Which of these changes is the most meaningful?
A. Quick ready setup as it has decreased at least 5 minutes of the procedure time to get Impella cannula primed.
Q Will the new Impella increase its use despite data that cannot be called robust?
A. Certainly newer Impella CP will increase overall CO and improve hemodynamic and I believe will be extra beneficial in pts with hemodynamic compromise such as Cardiogenic shock.
Q Are reimbursement issues still challenging for Impella?
A. Actually reimbursement for the hospital has not been any problem in appropriate cases. Rather it is simple, predictable and beneficial for the hospital point of view. Also now as of November we will have CPT codes for the physician reimbursement; for Impella insertion and Impella removal.
Q Always Bivalirudin with Impella?
A. Yes in our lab and make sure ACT is >300sec.
Q Having watched your webcast religiously, I feel that compulsive attention to vascular care (both placing and removing sheaths) greatly contributes to your reduced complications. Is this correct?
A. It is correct that vascular complications is the major morbidity in our interventional cases and hence minimizing them will improve overall pt's outcome and comfort.
Q Which of the support catheters do you find most user-friendly? Which of these should be a must-have in every cath lab?
A. There is no single one but certainly you need to have minimum Finecross and Corsair catheters and Guideliner in the cath lab to tackle all complex and CTO cases successfully.
Q Congratulations on the 2010 NY State report - what are the major factors contributing to this outstanding success?
A. A systemized protocol driven cath lab operation has yielded superb results year after year for last 10 years. We will discuss more during November webcast.


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