CHIP: As Access to High-Risk Care Expands, Patient Population Grows More Diverse
The day before ACC.16 officially kicked off at McCormick Place Chicago, interventionalists and other stakeholders gathered for The Interventional Toolbox for Complex Higher-Risk (and Indicated) Patients (CHIP) event, sponsored by the Cardiovascular Research Foundation.
Jeffrey W. Moses, MD, of NewYork-Presbyterian Hospital/Columbia University Medical Center in New York City, detailed the changes happening in patient demographics and benefits of hemodynamic support for high-risk patients undergoing PCI. Noting that the population is aging, Dr. Moses acknowledged the fragility of patients who are not suitable for surgery.
“Those patients who are not suitable surgical candidates, it’s a totally different ballgame,” said Dr. Moses. “If you’re a surgically ineligible candidate, your mortality is seven-fold higher than if you were a surgical candidate with exactly the same risk score.”
He also noted a large, currently undiagnosed group of patients who could benefit from revascularization, outlining the goals and use cases for hemodynamic support. He discussed the array of device choices, noting that the Impella® family of heart pumps are the most utilized.
Ajay J. Kirtane, MD, SM, also of NewYork-Presbyterian Hospital/Columbia University Medical Center followed with a recent case review, featuring an 81-year-old woman with non-STEMI chest discomfort, moderate LV dysfunction, moderate to severe AS and multi-vessel disease. While awaiting PCI, she developed severe chest pain and went to urgent PCI where Dr. Kirtane elected to use the Impella 2.5™ device with a small sheath. Based on the small size of the patient, access via the device was chosen because of its distal taper. As Dr. Kirtane explained, if the patient were to become ischemic during the procedure, the larger peel-away sheath can be taken out and the repositioning sheath easily inserted.
After a bout with contrast-induced nephrotoxicity, the patient recovered and went home to continue her active lifestyle.
Watchful eyes and growing CTO numbers
Presentations next turned to the risk-treatment paradox. The highest risk cases have the greatest incremental mortality benefit from treatment, though the least desirable to treat based on absolute mortality, according to James M. McCabe, MD, of the University of Washington in Seattle.
In an era where there is increasing transparency and growing use of performance metrics, Dr. McCabe noted that some stats miss the mark. While public reporting of a facility’s stats will make front-page news, follow-up investigations showing that some “low-performing” center are often taking on higher complexity cases are not as publicized. In fact, chasing scorecard perfection may be a fool’s errand.
“If you work at a center that has 100% on any scorecard measure you’re either a.) not doing enough of that procedure, b.) someone in your group is lying or cheating, or c.) you have focused on that measure to the detriment of other unmeasured performance characteristics,” said Dr. McCabe.
The discussion then shifted to patients with complete blockages requiring treatment with chronic total occlusion (CTO) PCI. William L. Lombardi, MD, also of University of Washington Medical Center, shared data on the rising volume and success rates of CTO PCI. New techniques and education programs are bearing fruit, but there’s more work to do. “Our standard of care is not where it should be,” he noted. “There is more we can do. People who do more of a thing are better than people who do less of a thing. We all need to do more cases to get better. There is a series of strategies, find the one that works and be willing to take on harder patients. Remember [when looking at images], it is not just a picture. It is a patient who needs to get fixed.”
Emmanouil S. Brilakis, MD, of VA North Texas Health Care System and UT Southwestern Medical Center in Dallas, presented his own case of a CTO patient, this time featuring a 56-year-old man with class III angina and frequent hospitalizations. He had previously undergone RCA PCI and LAD PCI eight and six years prior, respectively. Dr. Brilakis explained that strong guide support is critical in cases of in-stent restenosis CTO PCI. He also noted that for bifurcation at the distal cap, an interventionalist may need to perform two crossing to preserve both branches.
For these complex patients, practice makes for better outcomes and operator volume is associated with decreased major adverse cardiac events. Dr. Lombardi also urged his colleagues to learn new skill sets. “If you’re going to perform CTO PCI at your center, you need them all,” he said.
“It’s like if you play golf and all you can hit is the driver, you’re not going to be very good at golf,” said Dr. Lombardi. “If you can hit all 14 clubs in your bag, you’re going to be a much better golfer. And in this day and age, if you’re going to do CTOs, there’s a lot of clubs you’ve got to learn how to hit.”
The Impella 2.5 system is a temporary (<6 hours) ventricular support device indicated for use during high risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, including a cardiac surgeon, has determined high risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 in these patients may prevent hemodynamic instability which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.
Protected PCI and use of the Impella 2.5 is not right for every patient. Patients may not be able to be treated with Impella if they have certain pre-existing conditions, which a cardiologist can determine, such as: severe narrowing of the heart valve, severe peripheral artery disease, clots in blood vessels, or a replacement heart valve or certain heart valve deficiencies. Additionally, use of Impella has been associated with risks, including, but not limited to valvular and vascular injury, bleeding, and limb ischemia in certain patients. Learn more about the Impella devices’ approved indications for use, as well as important safety and risk information at www.protectedpci.com/indications-use-safety-information/.