Total Revascularization of High Risk Complex 68-year old Patient: ACC.16 Live Case Wrap-Up
William L. Lombardi, MD, Mark Reisman, MD, Ravi Hira, MD, and Robert Riley, MD, of the University of Washington Medical Center in Seattle presented a live case at ACC.16 on April 2 in which they performed a Protected PCI with Impella on a high-risk patient.
The team performed the procedure on a 68-year-old man who was referred for complete percutaneous revascularization and had a history of coronary artery disease and moderate to severe chronic obstructive pulmonary disease.
In 2003, he had a stent implanted in his left circumflex artery for unstable angina. Since then, he was relatively stable and had few symptoms until October 2015, when he had an episode of acute decompensated congestive heart failure. At that time, he underwent an echocardiogram that showed a left ventricular ejection fraction (LVEF) of 20%, up from 55% previously.
The patient also had severe left ventricular dilation, but he did not have major valvular abnormalities. He was then sent for an angiogram, which showed a chronic total occlusion of the distal left circumflex artery, including a large obtuse marginal branch, as well as a chronic total occlusion of the distal right coronary artery, including a co-dominant posterior descending artery and posterior left ventricular branch.
The patient was treated with a beta-blocker, ACE inhibitor and spironolactone and was turned down by a surgeon for CABG based on his comorbidities and the severity of left ventricular dysfunction. He was then referred to Drs. Lombardi, Reisman, Hira and Riley.
“This is an appropriate case [for the Impella],” said James Aaron Grantham, MD, a panelist and the director of cardiovascular medical education at Saint Luke’s Hospital in Kansas City, Mo. “His ejection fraction is less than 20 percent, which makes him a high-risk patient.”
During the procedure, Dr. Lombardi showed the audience the patient had an old stent as well as coronary collaterals.
“I think this is a classic case of using hemodynamic support if something went wrong here,” said Emmanouil S. Brilakis, a panelist and the director of the cardiac catheterization laboratories at VA North Texas Healthcare System. “I think the choice of Impella is very good. I think CP is a good choice for supporting any complications that arise.”
“I think [the Impella] was a great choice,” Dr. Brilakis said. “This patient was very stable. There was great flow and the person had no EKG changes and was very stable. It was very, very smooth. It worked out very well. This was a high -risk patient with very little reserve. If the slightest thing goes wrong, you may get in big trouble. I think this is an ideal example for hemodynamic support devices.”
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/hcp/information/isi.