Watch the first ever, Live Case Complex Coronary procedure livestreamed from Georgia Heart Institute’s cath lab to the Inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia. Join Nima Ghasemzadeh, MD, Falgun Patel, MD, and their team from Cath Lab 5 as they present an interesting case. Habib Samady, MD, President of Georgia Heart Institute, along with Symposium panelists observe, commentate, and ask questions as the Interventional Heart team give an inside look at a Complex Coronary case.
Let's please go now to lab five and Neema. Yeah good morning everyone. Um And one of the interventional cardiologist with the Georgia Heart institute um pleased to present you this live interesting uh complex corner case from northeast Georgia Medical center game. Maybe you want to take a minute and introduce your team there. Yes. Absolutely. So on my left I have the doctor Falcon Patel who is one of my partner interventional cardiologists. We are very pleased and uh privileged to have dr Bill Nicholson from Emory University with us today we have a phenomenal group of Cath lab staff with us today um Francisco Gonzales, we have melissa um Holcomb. We have Kerry, true love on the control room. We have Chase McDowell and kim Boykin. We also are pleased to have unfortunate to have our sponsoring team from uh phillips uh and Abbott and also are phenomenal uh anesthesia team who will be supporting us during this case. So without further ado let me just say hi to Bill and Falcon. Hi guys good morning. Good to hear your voice and it's nice to nice to be here, appreciate the opportunity. Yeah thanks for joining us. Go ahead Neema. Yeah so we have a great complex coronary case. I have no disclosures if you could uh go to the next slide please. So this is a very pleasant 76 year old male with history of C. A. D. S. That was prior uh and here in my cord infarction in 2012 with P. C. I. Of the L. A. D. Proximal to mid segment in 2012 along with the P. C. I. Of the mixer complex coronary artery. Um He also has ischemic cardiomyopathy. With with LV. Ejection fraction that had recovered uh to 40% after revascularization. And with garland reckon medical therapy. Uh He also has end stage renal disease and he's on him a dialysis. Uh He has COPD and he's on homo too. He has type two diabetes, mellitus hypertension and this lipid E. Mia. He had a recent admission to Northeast Georgia Medical Center Gainesville with an honest elevation myocardial infarction when he presented with chest pain and had a peak high sensitive troponin of 1600. His medications include a duel and to play the therapy with aspirin and clopidogrel. Along with dual anti angina therapy with ice ordeal and Topo XL along with the statin regimen and insulin. So if you could could go back go forward please. Uh This is the data from previous hospitalization when he presented with non S. T. Elevation michael unfortunate as you can see E. K. G. Showing sinus rhythm. Uh And basically um some subtle changes in the lateral lisa just ischemia is LV. Ef on echocardiogram was 25% down from a baseline of um 40%. Go forward please. This is his left coronary angiogram showing previously implanted stents in the proximal to meet lady with moderate to severe uh instantly stenosis of the proximal to meet lady. Uh The stent appears to be coming back at the osmium. There is severe, probably calcification stenosis of the Osti um of the Sir complex in a large uh sir complex coronary artery I. F. R. Of the L. A. D. Was performed which showed significant ischemia. The lady territory with I. Four of 40.70 fairly diffused. Uh Perhaps uh step up on the phone call back. Go forward please. Uh He has a dominant right coronary artery free of an geographically uh severe stenosis. Um So uh this is his data from previous admission. He was referred to coronary artery bypass graft surgery. Our city surgery team evaluated him but due to his high risk uh features including uh pretty severe cardiomyopathy, also oxygen dependent COPD and end stage renal disease decision was made that perhaps cabbage was gonna be deemed high risk for him and therefore he was referred for complex pertaining scoring intervention. He was discharged from the hospital. He was trying to decide whether he wanted to continue with medical therapy alone versus complex pc. I. Um And uh he continued to have a significant life limiting angina and shortness of breath with minimal exertion. And therefore he decided to proceed with complex corner intervention. So here we are today um we obtained uh right coming from an arterial access using ultrasound technique and standard technique and uh with the goal of doing this case with in Pella assistance due to high risk features. Um He has depressed LV. Ejection fracture. There was a great likelihood that we're going to have to perform rotational threat to me. Of the austin of the circum flex. And his L. B. E. D. P. Was about 20 millimeters of mercury. So before implanting the impeller we proceeded with right heart catheterization at swan Ganz placement and his basically p a diastolic pressure was in the twenties. Uh Systolic pressure was in the forties. And uh therefore we decided to proceed with in Pella assisted high risk intervention of the digital left main uh involving the predominantly osteo sir complex but some involvement of the osteo lady. So we proceeded with our access and right common family artery. Using ultrasound we placed the impeller sheath that's our access, their uh placed our impeller sheet and successfully placed in Pella C. P. Catheter into the LV with successful um flow um achieving flow of around 2.8 to 3 point oh liters per minute. We uh using previously described technique we placed a seven french sheath alongside the impeller catheter as you can see uh just beside the impeller Catherine in the peel away sheath and proceeded with delivery of the seven french E. B. U. 3.75 catheter that was used to engage the left main coronary artery. Our anti coagulation today is heparin with the goal a cd of above uh 250 phenomenal nursing staff has been able to help us with that. And uh we then proceeded with O. C. T. Uh Neema. Let's let's stop there for a second. Um And that was a great presentation really a challenging case and again really a case that I first will go to some of my surgical colleagues uh because I know you all have seen the patient but um any any comments assessment in terms of appropriateness for revascularization here surgical versus Pc. I dan. Did you see this patient as well? I think I remember this guy as well. Um I think I mean this hopefully this looks pretty straightforward. I mean it's a high risk, high risk lesion but I think Bill, I know Bill Nicholson and and Neema and falcon will do a great job on this. Um Hopefully the patient will get a good response and and hopefully have significant improvement. Um So I think that the nice thing about this is this is a situation where it's really the patient's clinical comorbidities. Just for our whole audience. Right? I think the important thing, the important thing that Neema said to me is I think we initially tried to treat this patient medically and he failed medically. So I think that we brought the patient back. We talked to him at length he understands is a high risk procedure. Um He was under understood the risk prior to the procedure and that was fully explained to him and we're ready to roll. Well I guess my question just for the audience is from a surgical perspective this is prohibitive just getting him through. Is it mostly the homo too with C. O. P. D. Is that the dialysis is the combination? I think I think it's important to just air that out for the whole. I think one of the things you have to realize is that this patient in fact is not unlike numerous patients we operate on all the time. So his anatomy, I think uh let's just change, let's just change the perspective and say he had, you know, tandem multiple lesions in his L. A. D. You know, diffuse disease in the circle place coronary. So now he's no longer a great candidate for pc. I so what are you gonna do? And the point is that I think that, you know, the longer I see these patients, I'm always amazed at what can be accomplished with perky tennis interventions. And I think we have to be cognizant of the fact that sometimes but you know less is more. When you consider looking these patients, we have to be aware of the fact that homo two ended up itself um is a significant risk factor related to peri operative hypoglycemia. That leads to a whole host of issues wound healing issues, atrial fibrillation, re admission to the ICU re intervention, you know, re intubation uh in stage renal disease is by and large. Something we can handle. Well because we can deal with that from a standpoint of preoperative dialysis, get them the right volume curve and and that it can't get any worse. So it's not such a big issue. Um So I think that this guy's anatomy I think is particularly good if you will be interested to see how this comes out in terms of how you handle it. And I think the other thing you hear from the standpoint of the surgical perspective is the heavy calcification of his coronary artery, at least as far as the LED is concerned. So we suggest that if you were gonna put him on the heart lung machine to do bypass surgery, he's got a significant of of a peripheral vascular issues related to uh stroke and other things. We haven't really codified. Well by looking at his trans soft shell eco in terms of grading as the order caffe aroma. Um One option to consider in this patient would be to do him off pump. Um That would be uh not ideal. We would support this patient with interop balloon pump and do a circum flexes, isolated graft with a single vein graft and that could be done probably relatively low risk. Um You know, from that standpoint. So there are there are options from a surgical standpoint not to say that this intervention is not reasonable. Yeah. Spencer and Emma Emma feel free for you guys to get started. Just go ahead and get started discussing Ellen and short. He's a lousy surgical candidate surgical. Okay, so maybe while you get started, Bill Nicholson and and glenn Henry, do any of you have any thoughts on the case? Yeah. Thanks. I mean, I would ask you what what the panel said. I think a couple of things that come up, you know, from a clinical standpoint, you know, the guy needs to be vascular just from a symptomatic standpoint. He's got depressed. You know, you've got a number of good reasons to be here in the first place. And I think a surgical opinion as described by your panels is perfectly uh correct. You know, as far as I think they can get people through. I mean they do an amazing amazed at some of the people that can get through the operations. But at the same time, you know, this is a reasonable alternative strategy here. And I think put put a lot of thought into this. And I think when you start talking about strategy, I think it's very interesting. You know, I think that's the case. You know, you've got a lot of this is going to be image guided to kind of determine the correct strategy. I think we talked quite a bit about what the strategy would be here ahead of time and I think the imaging is gonna change sort of the uh the bifurcation technique that we're going to go for. And I think, you know, clearly have indications for the impeller. You know, I'm not a huge protected pc user. But I mean, I think when you look at this patient, even though he's got a mixed venus in the mid to low seventies, you've got pressure starting in the mid, mid to high forties. You've got a diastolic pressure of 20/20. It's important to the right heart cath you can't do these just by guessing. You have to have true numbers to understand what you're going to deal with. But I think, you know, you can certainly see that you may have to use some sort of a threat to me approach. And you know, you're gonna stun big sur complex myocardial. Um you already have an L. A. D. Territories question with viability. So you certainly can see the patient deteriorates. So I think the decision to go with protection in this case is absolutely spot on. I think doing it as a ship technique with a single access uh is just where the world is right now. You know, and I think it's doesn't complicate the case anymore than what it would be. And I think, you know, you've got some really elegant options is the best way to treat the the anatomy here based upon some of the imaging choices that falcon and have selected. And so they've moved along quite a bit because we knew you were in the other room and we didn't want to like have to fire through everything real fast. So we can show you what we've done all we can, I'd love to hear what one thinks as far as strategies as well. Great. Yeah. Yeah just tell us what you're doing or what you've done. So yeah. So uh placed a run through wire in the in the coronary artery followed by O. C. T. To characterize the nature of the I. S. R. And the lady. So uh coming if we can show the O. C. T. Images. I think initially we thought we thought we were gonna have some struts from the L. A. D. Into the left main. So we thought we were gonna do kind of a delayed mini crush or even maybe a delayed DK crush from whenever the original stent went in. But the O. C. T. Is interesting here. So uh if you want to walk through that. So here you can see the left main coming forward. We're coming into the bifurcation. That's the if you hold there, you see that, see the cirque coming in there at the side and you see one strut from the led going into you know going across the circle. So they truly did austerely stent the L. A. D. When they put this stent in. So you really we don't have any stent hanging out to convert to a mini crush or to convert to a DK crush. So I mean I think it almost begs for a T stent strategy just by the way they've where they where they put it in there. So I mean it does simplify that portion of the case quite a bit. I think without imaging you have no idea about that. Let you keep going there. I think just while you're doing this it's not a it's important to remind folks that these stents you mentioned were placed in 2012,012 in the setting. So I think just for the audience right if you have hypnosis and stent stir 10 years old. The question is when did these stenosis stenosis within the first six months or 12 months? In which case it's usually instant re stenosis. Or is this kind of delayed narrowing where you get neo atherosclerosis? And hopefully the O. C. T. Can give you insights and it may impact how you treat this. So we have the standing approximately. Lady in the Austrian appeared to be mildly undersized. The stand was a three oh the vessel appears to be 35. There is moderate uh to severe instant uh restenosis probably internal hyperplasia. And the and the proximity to meet L. A. D. Um There are some calcium behind the stands. Um It is important to note that this patient had anterior myocardial infarction before and previous stress. That showed in part in the territory of the L. A. D. The echocardiogram showed that part of the apex was perhaps card. So I'm not entirely sure how much of the L. A. D. S. Uh territory is viable. Our plan today was to basically perform rotational a threat to me of the um of the austin of the circum flex followed by uh stenting um of the circum flex back into the left main. Uh And pot approximate optimization technique for the left main followed by kissing balloon. And then we can image it and show it to you all to see if we're satisfied with the results. Uh And whether or not we need to carry forward with with anything. Uh For the lady now we show you the rotational are threat to me. This is 1.5 per at 260 RPMs. We do we did a couple of passes and it's uh it went through uh performed the lesion modification. Um There you go and keep going forward. Now here um We again ex exchange the wire wire, fine cross micro catheter and place the BMW wire in the circum flex, um coronary artery. Uh Then we went ahead and performed uh we we went ahead and perform a service of the circum flex and we can put the I. V. S. Images up. So here it is um The left main which measures around 5.0 mm 5.025 .25. Then we're gonna come into the um osmium of the sir complex which is right there as you can see there's eccentric calcified plaque and there's a gap in the calcification segment. Um So the rotational a threat to me. We think that probably did a good job and modifying plaque and hopefully we can get a good result with balloon angioplasty. Uh This is the proximal Sir complex coronary artery which shows some calcification. Uh and uh it measures around 4.0. Uh so here we are ready to perform a balloon angioplasty of the austin of the Sir complex followed by standing of the circum flex back into the left main. And we take it from there. Habib or any of our esteemed panel. If you all have any comments or questions, if you're like the world expert in imaging and so how much do we butcher all that interpretation were pretty accurate with what we thought about the Yeah. No, I mean I think that's that's spot on. I think uh honestly when you guys were discussing the different options for the bifurcation, the question was, how far back did the old lady stents come and would you do a reverse DK crush. But I think that really informed it. So let me ask. Um and I know Ronnie's ready to go and the next couple minutes let's ask um Angela and Glenn if either of you have any comments or how would you glen, how would you approach it? Do you have any comments on the case? Yeah, I mean I think the example of both of these cases is excellent about how to approach complex cases. It's all about risk mitigation and anticipation of risk during the case. Uh you know, simple things like putting the swan in before you put the um paella in to make sure the patient is stable for the procedure. We've taken patients off the table who are unfit to do a high risk procedure to get the medically tuned up. And you can't underestimate the importance of careful, thoughtful and methodical approach to these. They thought well, about where their imaging is gonna be, what kind of stenting procedure they're going to do. I think the importance of imaging in these coronary cases, they can't be underestimated because it can't be obviated. You have to do imaging angiography is too blunt a tool to use our modern technologies these days. And the results are just unacceptable unless you image. So I think they've done a nice approach here. They have a careful, well thought out plan. They're going down the road with the plan and things are going well and I'm sure you know, they've anticipated several potential bumps in the future and they have plans for those as well. Thank you, Glenn. Um for those comments. I think I just uh wanted to let you all know that, you know to uh tune him up, say for the procedure, we actually made him have an extra dialysis session yesterday. And also we did a traverse et a protocol to make sure that his peripheral arteries can handle impala insertion. Um and you know, make sure that if he's going, arteries were not good enough caliber we have at least evaluation of the subclavian arteries. Great. Well listen, let's let you guys work in lab five and let's go over to Ronnie and daddy's room and lab three OK, Neema and Calgon and Bill. We're back to you in lab five. Yeah, thanks. I mean um so has made quite a bit of progress here. He's done a very nice job. So you know, he did a hysterectomy already on the circum flex. We had imaged after that and thought that the calcium had had broken or really wasn't concentric to begin with, you know, but but certainly we anticipated that ballooning alone would probably open well and here's a four oh balloon. And this, you know, cirque left main you see expands very nicely with no waste. So we decided to go ahead instant ended up going with 40 stent basically getting, it's always important. Remember you need to get at least eight millimeters into the left main here because you need to pop that with the 50 balloon. And the shortest five A balloon you have is an eight. So you need at least eight millimeters of stents. You don't want to accidentally put two millimeters of stent in the left main and then you're stuck. You know, ballooning six millimeters of uncovered epithelium. And so so he did that go back to the second he could and his go to the one where you have an inflated in the distal left main. So this is nice. He's got, you always talk about where you have a lack of loss of parallel itty on the balloon. You can see how above the dots the balloon stays parallel to the other half of the balloon and then it starts to curve in or taper in. You want to put that that point of where you lose your parallel itty right at the corona like Emma's done there. This gives you your optimal potting situation. Uh It sort of opens up a strut to the L. A. D. For but more importantly, we'll put the stent to the left main so that if you were to touch the stent with the guide, you don't get malformation. So you always do that step a little bit ahead of time. I always do that before I go back and re cross. We're now going back to do our final kiss. So he's already recross the L. A. D. He used 15 balloon to open up the strut there. He's got a 35 based on my vista 35. Noncompliant. Sitting in the scheme of the L. A. D. Coming back into the left main. We had a four oh that we were going to post the circum flexible with. But the noncompliant balloons a little bulky didn't want to go. And I think we switched to a 35 regular balloon that will just go on high pressure in the circum flex. And so we'll do uh sir complex post dilatation first which is set up for there. So he'll go up to 20 atmospheres 18 or 20 atmospheres on the circum flicks. Uh he's got both balloons in place so he doesn't jail one access to the other. So, you know, you've got two balloons laying across both offices of the circum flex and left main. So and then you just do stepwise progression here. The post dilatation, he's lining his dots up nicely on the proximal edge. And so Falcon is gonna go up to 20 or 18 or 20 on the circum flicks. Okay, good. So maybe sending out to the crowd can see. So there you go, there's a certain going up high pressure and then you come down on that and then we'll go up high pressure on the L. A. D. Right, which may want a watermelon seed here. So we have to pull back a little bit as we do that. And so high pressure is 18-20. Uh and this we're expecting to give there, which it did. And then we're gonna do our final Kiss here, which is only at 68 atmospheres. This is just forming the the stent together. And so just together and you say that that's your final kiss. And then we're gonna come down with both of those. And then we'll back that out and take a picture. And obviously image to see that we've got, you know, kind of goal sizes of all the different uh final uh measurements, which would be the, you know, the approximate sir complex approximate led the Carina and the left main. And they're sort of kind of standard numbers that we're trying to reach with that. But I think we're going to be well over those with the sizes of what we've got here. So I think they're really gonna end up with a nice result. Be interesting to get a quick picture here. I know you guys are at a critical step next door and I'm sure nobody wants to see that actually impelled come out or axillary access come out if you're gonna have time to do that. But you can see we've moved the LED a little bit, so it's not laying right over top. That looks really, it looks pretty aggressively and well sized there. And I think the imaging helped you put that, was it a four oh stents? And the circle back to the 440 23 stents 4 20 in the circuit. And we just did a kissing bottom for the LED. I think you really got, you know, a nice result in the circum flex big. It's well expanded the L. E. D. I think, you know, that the imaging, it was incredibly helpful here, as far as guiding, how to approach that bifurcation. I think, uh I think it's a beautiful results, Well, images and get everything out of here, but I think they did a beautiful job. I think all the kind of interesting cool stuff over with, but and we'll redo the swan numbers at the end just to kind of see whether we had any change in human dynamics, but he's been rock stable the whole way through with pressures in the one thirties to one sixties the whole time. So I think it's a great case really is. Yeah, No, thank you so much for demonstrating that. And so basically the imaging of the L. A. D. Showed you that you really didn't need to stand the led, you just ballooned it right? And so you had a single single crossover stent from the circle back to the left main kiss and then post dilated. Are you guys gonna finish with a pot or you're going to see what the imaging shows and take it from there? It's a good debate. I mean, some people think you need to re pot. I personally don't, there's, you know, there's data out of Colombia that looks like, oh, Valerie versus a circularity of the final result. Because, you know, you kind of, when you kiss, you sort of turn this sent into a little bit of an oval, but you know, again, that's something that you're a world expert on. So I know you have different thoughts on that. So it's uh, I'm not sure what the right answer is, but but we we we certainly can. It's not not hard to do well, no, that's fantastic. Um So before we go back to the structural room um I look at the coronary experts and uh yeah please do let me ask you while you're showing that Angela taylor or any comments? Yes. Fantastic result. Very well handled. I will make a couple comments just technically when you think about bifurcation like this, we have a little luxury here because there's a stent already in the L. A. D. So that makes things a little easier when thinking about the circum flexor is obviously options stenting to the osteo, sir, extending back into the L. A. D. I think it's important to point out here that bifurcation angle is much less than 90 degrees. So t stunting is not gonna be too optimal of a choice just because you're gonna miss part of the osteo. Um When you bring the sent back into the left main, you want to make sure it's back far enough that you don't have trouble re crossing into the LED. Um If you need to cover the OST E. Um of the left main, I think it's very helpful to go to the L. A. Cranial so you can see where that true Osmium is always look into views don't take one because that can be a little bit tricky where that actually lies. Um post imaging is critical. Um But I think they handled this really, really well. This is a great result. Fantastic. So uh do you want to go over the office? We'll show the iris images if you don't mind. Yeah. So this is a diverse post double casing. I this image of the Sir complex to left main. And uh when we're coming back here, you can see the stand age. We don't see any major dissection. It landed in the list and 30% applied. Really good expansion of the standard whether uh we can see all that. And this is a proximal age of the uh Sir complex artery. And this is where the Austrian of the Sir complex is. And you can see the area here is uh 7.3 millimeters square where the maximum calcium and the disease was. And this is our stand and right after that this is where the led coming up at five o'clock. And you can see the standards very well expanded in the left main and beautiful circular. And we'll listen guys, let me just ask for an applause for our coronary room because I was a phenomenal case. Again, a very high risk individual that was as it were not a surgical candidate. And you know, got a really really nice results. So I want to thank Lab five and Neema Calgon Bill Bill, thanks for joining us as always providing your insights. I know you're gonna try to come over and give us a talk on C. t o p c i here and thanks for the lab. Five staff. Fantastic work.
