TCT 2015 Live Case Demonstrates Success with “Undoable Case”
On Monday afternoon at the TCT Conference, Drs. David Kandzari and Nicholas Lembo from Piedmont Heart Institute in Atlanta, GA presented a live case from the catheterization laboratory in the session entitled “Valvular Heart Disease and Complex and High-Risk Interventions” broadcasted in the Main Arena during a session moderated by Dr. Marty Leon.
The patient was a 71-year-old female smoker (60 years of tobacco use) with chronic obstructive pulmonary disease, pulmonary hypertension, hyperlipidemia, diabetes, and a prior stroke. She presented with respiratory failure, class IV heart failure, and non-ST-segment elevation myocardial infarction (non-STEMI).
Angiographic results indicated stenosis of 75% in the left main, 95% in the left circumflex artery, 95% in the right coronary artery and 75% in the left anterior descending artery. Her ejection fraction was 25%, SYNTAX score was 46 and STS was 11% mortality. The patient was not eligible for coronary artery bypass surgery (CABG) due to left ventricular dysfunction.
The treatment strategy was Protected PCI for the right coronary artery followed by PCI of the of the left main, left anterior descending artery, and left circumflex artery for PCI guided intravascular ultrasound with hemodynamic support. Dr. Leon agreed the goals of treatment were to take care of the proximal left coronary system. Dr. Kandzari noted that the hemodynamic support provided by Impella allowed for rotational atherectomy using CSI atherectomy. Heparin was used as the anticoagulant.
Dr. Leon noted the importance of having hemodynamic support with Impella during this procedure when he said, “Having a support device in makes all the difference,” and stated on the big screen SMS text message monitor that “the slow flow in the left anterior descending artery would be poorly tolerated without Impella support.” The result of the procedure was the placement of three stents: one in the mid left anterior descending artery, another in the left circumflex artery, and one in the left anterior descending artery.
This case highlights the potential benefits which Protected PCI with hemodynamic support can provide for patients with comorbidities that are not eligible for CABG and have no treatment options. Dr. Leon estimates about 100,000 people a year fall into this category. He noted that, “we are trying to create centers that do this complex supported angioplasty. A lot of these are post-surgical procedures. A lot of angina and a lot of high blood pressure. It’s like the elderly aortic stenosis patient, they’re sitting somewhere and no one is treating them.”
Dr. Leon also discussed the role of surgeons in these high risk cases, “surgeons are the largest referral source for these [high-risk PCI] patients that have comorbidities and no options….with hemodynamic support and techniques for achieving complete revascularization, that’s a key driver. If we can achieve as much complete revascularization, then I think that’s a positive for PCI.”
Dr. Leon closed the live case session by stating to Dr. Kandzari, “This has been a very instructive case. This is a great result and example of an ‘undoable case’ – thanks for sharing.”
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/.