Challenging Impella-supported Protected PCI Cases

State of the Art Approach for Optimizing Patients Prior to TAVR

Dr. Siddharth Wayangankar discusses his protected PCI strategy for managing patients with severe aortic stenosis and low EF with multivessel disease, specifically difficult to stent distal left main lesions. “The bottom line is that these patients need complete revascularization before considering TAVR,” he tells interviewer Dr. Seth Bilazarian.

Dr. Wayangankar presents 2 cases illustrating his approach in this patient population. The patients have critical aortic stenosis, low ejection fraction, and multivessel disease including significant calcified distal left main disease. As he tells Dr. Bilazarian, his approach is not to touch the aortic valve with balloon angioplasty. He uses Impella CP® to cross the stenotic aortic valve, and once Impella is in place, he explains, “the output that it gives you, gives you stability to perform the complex percutaneous coronary interventions.”

Dr. Wayangankar explains that in both patient cases his team put in Impella, fixed the right coronary artery, then proceeded with double kissing crush (DK Crush) stenting of the distal left main with excellent results. Both patients came back in 1-2 weeks for TAVR. He is currently following 5 such patients and all of them are doing well, back at NYHA Class 1 with normalized ejection fractions.

Dr. Bilazarian comments that this approach of using Impella-supported protected PCI to give the best coronary outcome first “is a very sound way of optimizing these patients for their ultimate definitive therapies.”

Dr. Wayangankar explains that some of these cases are more straightforward and can be done without mechanical circulatory support. However, he believes that with data supporting DK Crush for the distal left main, Impella support enables him to focus on the complex bifurcating stenting. “Put Impella in, do the best PCI that you can, and then do the TAVR is what my recommendation would be,” summarizes Dr. Wayangankar.

Dr. Bilazarian confirms, “I think that there’s a lot to learn about patients with concomitant coronary disease and aortic valve disease, but I think this approach is probably the state of the art as we stand right now.”

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