PCI of Calcified Tortuous LAD/D1 Bifurcation via Evolut-TAVR Struts – April 2024

Case and Plan

78-year-old male with known CAD and severe AS underwent successful Evolut FX TAVR on February 8, 2024. A Cardiac Cath on Feb 8, 2024 revealed 2 V CAD: ostial RCA CTO and 80% angulated tortuous severely calcified LAD/Diagonal bifurcation lesions with SYNTAX Score of 18 and EF 60%. Patient continued to have exertional dyspnea with normal functioning TAVR valve. Now planned for complex PCI of calcified tortuous LAD/D1 bifurcation via Evolut-TAVR struts.


Q What were your concerns about using IVL in today's case?
A. My only concern about upfront use of IVL was, inability to deliver the IVL catheter. Otherwise RotaTripsy is a commonly practiced strategy in our lab making about half of the Rota cases.
Q Can you explain the complications that could occur with PCI in TAVR cases?
A. Post TAVR, biggest issue is the selective engagement of the coronary Ostia. Hence poor support and sometimes guide induced coronary or aortic injury always remains a concern. In addition lack of LV support by Impella during hemodynamic collapse, although can be done but due to reports of damage to the TAVR valve, caution has been recommended. Other PCI complication of calcified lesions intervention remains the issue.
Q What should be the guidelines for hardware use for such cases?
A. For PCI post TAVR, besides selecting a smaller guides, liberal use of guide extension catheters and ballon support is recommended.
Q Is there a role of preventative PCI (non-severe lesions) before TAVR using self-expanding TAVR?
A. The concept of preventative PCI of non-severe lesions pre-TAVR specially in cases of planned self-expanding TAVR use may not apply as most of these lesions are calcified and unlikely to be vulnerable plaques. Hence PCI guided by angio or FFR/iFR remains the main stay of decision making in TAVR pts; pre or post.
Q What are the pragmatic tips you have to avoid vascular complications with Impella?
A. Essential important tips to avoid/minimize vascular complications with Impella (14Fr) is first to evaluate the vascular access by angio or CTA. Then use of vascular US for micro puncture to establish the correct puncture site, then inserting 8Fr sheath followed by 1-2 Perclose sutures on 8Fr sheath and finally advancing the 14Fr Impella sheath on the 0.035” stiff guide wire. Also keep ACT around 300sec with heparin or Bivalirudin. Following these steps rigorously, our major vascular complications with Impella is under 2%.
Q Is Impella mandatory for centers that offer STEMI Interventions?
A. I always believed that Impella availability is mandatory at STEMI PPCI sites and have practiced that policy in our 3 stand alone cathlabs in the Sinai system. Now the +results of DanGer Shock trial, further reinforces the Impella mandatory policy at PPCI labs.
Q Regarding the Prevent trial and its implications, what do you feel will be the best modality to determine a vulnerable plaque?
A. Prevent trial results although expected but is really ground breaking and has a potential to change our interventional practice in high CAD risk pts for vulnerable plaque (VP) detection. In my opinion best imaging marker of VP is ThinCapFibroAtheroma (TCFA), which can be best identified on OCT. Hence OCT is the best modality to detect VP.
Q Are there situations already present in 2024 where Preventative PCI may be justified?
A. It will take us 2-3 more + trials like Prevent trial, to start justifying PCI of VPs. Until then continue aggressive CAD risk modifications including use of PCSK-9 inhibitors.
Q Of emerging micro axillary flow pumps, which appears most promising?
A. Next generation of micro axillary flow pumps will be 9-9.5Fr and will provide up to 5L of blood flow. Magenta medical and ECP of Abiomed are very close to the finish line and should be available in next one year for clinical use.
Q Are more of your patients now using anti-obesity drugs?
A. Yes many of my patients are using Ozempic or Mounzaro with great success in loosing weight. The key issue will be to see if they can maintain the reduced weight. Rough data are that their has been 1/3rd reduction in Bariatric surgery in the USA in last 2 years; of course largely driven by use of antiobesity drugs.


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