Impella Buys Time for Complex Procedures: ACC.2016 Live Case

Barnes Jewish #1A live case transmission presented at the American College of Cardiology 2016 Scientific Session on April 3 turned into a lesson on patience, as well as the necessity for hemodynamic support.

Broadcasting from Barnes-Jewish Hospital in St. Louis, John M. Lasala, MD, and Jasvindar Singh, MD, tackled the case of an 84-year-old man with severe multivessel disease featuring a 90% calcified mid RCA and 80% tandem calcified proximal and mid LAD stenoses.

With an ejection fraction at 20 percent and blood pressures of 90-100, the patient would need assistance during the atherectomy procedure. “I think the complication of those events really mandate hemodynamic support,” said Dr. Lasala.

Barnes Jewish #3The panel of experts observing from Chicago agreed. “This does deserve support to really perform this complex PCI in a relaxed fashion and even if something goes wrong, you know that you will have a safety net,” said Giora Weisz, MD, of Shaare Zedek Medical Center, Jerusalem.

Dr. Lasala explained that they were using the Impella 2.5™ heart pump for support, and that they also placed a Swan-Ganz catheter.  Ricardo A. Costa, MD, of the Dante Pazzanese Institute of Cardiology in São Paulo, Brazil, noted that while he doesn’t routinely use support for complex interventions, this was a case where it was warranted.

Halfway through the procedure, the need for hemodynamic support was underscored during a lengthy application of rotational atherectomy.  It took seven or eight passes before the burr passed through the calcified lesion. “People who are doing rotational atherectomy with the Impella in place clearly can go for a much longer time, and do a more thorough job,” said Dr. Lasala.

Barnes Jewish #4“With this kind of complex case, you need patience,” added Dr. Singh, and without hemodynamic support, there’s less room for patience. “Imagine trying to heal this lesion with a balloon.”

Panelists echoed the need for patience, urging the operators not to settle for “just OK” stent expansion, even going back with a bigger burr if necessary. “You don’t want the patient coming back to the lab,” said Sunil Rao, MD, of Duke Clinical Research Institute.

Persistence paid off, and while it took extra effort, the case was handled without major complication.

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