‘RotaTripsy’ of Tortuous Calcified LAD/D1 Bifurcation – July 2021

Case and Plan:
66-year-old female with Class I angina had low risk stress MPI as a pre-op for knee surgery. A Cardiac Cath on March 28, 2021 revealed severe 3V CAD with SYNTAX Score of 20 and LVEF = 60%. Patient was cleared to undergo knee replacement surgery under medical optimization. Patient was brought back to undergo PCI and underwent staged PCI of LCx-LPL on July 18, 2021. Now planned for imaging guided tortuous calcified mid LAD/Diagonal bifurcation using RA + IVL (RotaTripsy) and dedicated 2-stent Mini-Crush technique.


Q The Rota Tripsy strategy seems promising?
A. Indeed RotaTripsy synergy is very promising by avoiding bigger Rota burr (and replacing it with IVL) and it's attended complications.
Q The most attractive feature about IVL seems to be its ease of use?
A. That is correct as with IVL, there is no learning curve and easy to use. Need to pre-treat the lesion in 50-60% of cases before advancing the IVL catheter.
Q What all ablative therapies can IVL complement?
A. IVL can complement all ablative therapies or RA, OA or ELCA. Most importantly will help in avoiding bigger rota burr, higher orbital speed or larger excimer catheter usage.
Q If there was reimbursement, would Rota Tripsy diminish significantly?
A. Once there is CMS reimbursement for IVL, then some cases will be done as stand alone while many will still require Rota due to severe calcified lesions, to pave the way for IVL passage which otherwise will be tough to cross the lesion.
Q Do you see the expanding role of IVL?
A. Yes IVL because of ease of use will continue to increase its adoption in the Interventional cardiology armamentarium.
Q If IVL grows, does it do so organically or at the expense of other ablative therapies?
A. That is correct that half of the IVL growth for treatment of calcific lesions will come by replacing other ablative therapies and other half will be organic by increasing calcified lesion treatment. Currently severely calcified lesions are encountered in approx 10% of cases and Atherectomy is used in about 5% of PCI in USA. Hence there is still a significant treatment gap.
Q What are the limitations of IVL?
A. Most important limitation of IVL is its bulky nature and limited pulses (80) per catheter. Of course high coat of $4700 per catheter.
Q Its most attractive features?
A. Simplicity of use is the most attractive feature of IVL. Also console is small and readily portable.
Q Do you feel IVL can become mainstream therapy
A. Yes in my opinion, Rotational Atherectomy and IVL are the 2 devices which soon will dominate the calcified lesion treatment market.
Q Because of overlapping indications in the periphery and in coronaries, it appears that IVL would stack up against Orbital Atherectomy?
A. I personally believe that Orbital Atherectomy does not have the long term future at least in the coronary intervention field.


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