Complex PCI of Heavily Calcified RCA using Rotational Atherectomy and Ostial Flash System – Oct 2014

85 year-old male with longstanding stable angina controlled on medical therapy now presented with CCS Class III angina. A Cardiac Cath on September 5, 2014 revealed III Vessel CAD, multiple calcified lesions in RCA, LAD, LCx with severe systolic LV Dysfunction (LVEF 26%); SYNTAX Score of 42.5. A Cardiac MRI revealed myocardial viability in all three vessel distribution segments. Patient was recommended CABG and after the Heart Team discussion, patient and family declined CABG. Then patient underwent rotational atherectomy followed by the Promus PREMIER DES (3.5/28 & 3.0/28mm) in proximal and mid LAD. Patient has multiple 80-90% calcified lesions in RCA including ostial lesion. Patient is now planned for complex PCI of heavily calcified RCA incorporating rotational atherectomy and Ostial Flash System.



Q Your decision not to use either IABP or Impella in this case was very correct and very experienced. If you had to choose one therapy, which one would it have been?
A. In view of LVEF >50% in this case, IABP use will suffice as per our published algorithm. Impella will be useful if LVEF <35%; that was also the inclusion LVEF in LM pts in the PROTECT II trial.
Q No need to use Gp2b/3a in such cases?
A. Just because of the old age, routine use of GP 2b/3a inhibitor is not recommended. In cases of any procedural complications such as slow flow, side branch closure or residual minor dissection, GP inhibitor bolus only will be recommended as long as there is no contraindication to their use. We prefer weight adjusted 2 boluses of IV Eptifibatide 10 minutes apart in such situations.
Q In addition to reducing bleeding, what additional benefits come from using Bivalirudin?
A. Reduction in bleeding is the major benefit of Bivalirudin while all studies have showed significantly higher acute (<24Hrs) stent thrombosis and a non-significant (0.6%-0.8%) higher major ischemic events with Bivalirudin use.
Q Did the Bivalirudin short life help in managing the minor wire perforation?
A. Yes and that has been our experience (published in Cathet Cardiovasc Intervent 2009;74:700) but no available antidote to Bivalirudin has made many interventionalists cautious in perforation situations. Hence many avid Bivalirudin users, do not use it in CTO cases.
Q You mentioned not using Orbital Atherectomy - is it a complete contraindication for ostial lesions?
A. In my opinion, in aorto-ostial lesion orbital atherectomy is contraindicated as there will be no limit to vertical motion of the crown and has a potential to cause dissection/perforation.
Q In ways, the Flash Ostial resembles the Inoue balloon for mitral valvuloplasty?
A. Yes and has 2 separate balloons for specific purposes; one to stabilize the balloon which is sized with stent size and other to plaster the protruding stent struts against the wall and is usually 8mm.
Q Any other ostial devices that appear promising on the horizon?
A. Few others have been introduced and no longer available and only Ostial Flash balloon is being clinically used at present.
Q So, the final word in A. Fib post stent management is Clopidogrel and Warfarin? How much INR should we maintain?
A. That is correct, Clopidogrel +warfarin seems to have the best data (bleeding safety along with best efficacy) with keeping INR between 2-2.5. However we have no consensus once newer anti-thrombotics are used; 2 ongoing trials will identify the best combination by next year.
Q In this case, you beautifully demonstrated use of Rotablator - how often do you upsize burrs? More important, do you end up down-sizing sometimes too as you did in this case, or it is extremely rare
A. We do approx 50 cases of Rotablator per month and upsize the bur in 2-3 cases (<5%). Yes downsizing the burr for various reasons happen in about 10-12% of cases.
Q No issue about the guideliner almost reaching a distal lesion, does it not Dotter or cause intimal injury?
A. Yes we need to be extremely careful about advancing the guideliner in distal lesions; it should be done after distal balloon anchoring to minimize the chances of coronary dissection and intimal injury.


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