Complex coronary cases
Complex PCI of RCA and LAD using Rotational Atherectomy and DES – Oct 2013

79- year- old female with multiple CAD risk factors, prior MI and CVA presented on Sept 10, 2013 with Non-STEMI and CHF. Cardiac cath revealed calcific severe 3V CAD and LVEF 22%, with a SYNTAX score 23. Cardiac MRI revealed viability in all segments. CT surgery consultation obtained, but CABG was declined. Patient is now scheduled for complex PCI of RCA and LAD using rotational atherectomy and DES with a left ventricular assist device.

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Q&A
Q
What important enhancements have been made to the Impella catheter?
A.

Quick set up, newer LCD display showing position of Impella catheter and red tubing for retrograde insertion of the guidewire into the the Impella catheter are important recent enhancements.


Q
Is Impella mainly for high-risk, supportive angioplasty or does it have a role in AMI too?
A.

Published data do support Impella use for both high risk PCI as well as AMI with Hemodynamic compromise (USPELLA registry), but 80-85% use is in high-risk PCI.


Q
How do you decide between the 2.5 and 4 litres Cardiac Output device?
A.

Impella CP with upto 4L CO is useful in pts with hemodynamic compromise and cardiogenic shock.


Q
How many cases are needed with the Impella catheter to be proficient?
A.

There is no clear number but with overall ease of use, my recommendation will be to do 2 Impella cases under supervision to become proficient.


Q
What are some of the improvements that can still be made with the Impella catheter?
A.

Most important future development should be to decrease the catheter and sheath size to 9-10 Fr (size of the distal Impella catheter).


Q
Always Bivalirudin with Impella? How much do you keep the ACT?
A.

Yes all cases of Impella at MSH are done with Bivalirudin with ACT minimum over 300sec. Less than that may cause thrombus on the Impella catheter.


Q
Have there been any situations in which the Impella catheter was left in post procedure?
A.

In all high risk cases, we have removed Impella after PCI in the Cath lab. In rare cases of post MI and shock situations, we have left Impella upto 3-5days.


Q
Has the Impella catheter fully replaced Tandem Heart?
A.

Yes in our Cath lab we have not used Tandem Heart over last 3 years and we use Impella in 3-5 PCI cases per month.


Q
Approximate what percentage of your supportive angioplasty is with IABP, Impella, Tandem Heart and ECMO?
A.

Of the average 410 PCIs per month, we use IABP in 30 cases, Impella in 4 cases and 0 Tandem Heart. ECMO is used once every 2-3 mths (1 per 800-900 PCI cases).


Q
Which of these is the most promising for high-risk PCI? All?
A.

All 3 LV support devices will be useful based on the degree of myocardial jeopardy, LV dysfunction and Hemodynamic compromise (as shown in Algorithm slide in my presentation).


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