Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
POST CABG CHALLENGES
Petros S. Dardas, MD, FESC
St Lukes’ Hospital
Thessaloniki, GREECE
• PROCTOR
– TAVI (MEDTRONIC)
– ROTABLATION (BOSTON)
The future: treat native coronariesinstead of SVGs?
CASE 1
• 68 MALE
• 2015 CABG
– LIMA LAD
– RIMA BIG IM
– SVG RCA
• 4 MONTHS LATER: INCREASING ANGINA
LHC• 100% LIMA LAD distally
• SEVERE STENOSIS DISTAL RIMA –IM
• 100% SVG RCA
1ST PCI • NATIVE RCA
• DISTAL RIMA - IM
1st PCI
RCA pre RCA post
1st PCI
RIMA pre RIMA post
2ND PCI
• RETROGRADE OSTIAL LAD CTO
2ND PCI
Pre 1 Pre 2
2ND PCI
Pre 3 1.5 mm balloon LMS-Cx
2ND PCI
ENHANCER RX LMS CXENHANCER RX CONFIANZA PRO -LAD
2ND PCI
TURNPIKE LP –de-escalation GAIA II GAIA II in false lumen
2ND PCI
RETROGRADE INJECTION THROUGH TURNPIKE
2ND PCI
SION inability to cross SION BLACK
2ND PCI
SION BLACK DIAGONALREVERSE CART GAIA II unable to cross
2ND PCI
REVERSE CART GAIA II unable to cross REVERSE CART PILOT 200
2ND PCI
PILOT succesfull RG3 externalization
2ND PCI
ENHANCER RX PROXIMAL LADENHANCER RX GAIA II unable to cross distally
2ND PCI
ENHANCER RX BIFURCATION LAD SEPTAL
ENHANCER RX GAIA II SUCCESFULL REENTRY TRUE LUMEN
2ND PCI
BMU true lumen LAD ballooning
2ND PCIFINAL
CASE 2
• 44 male
• Familial hyperlipidemia
• 2006:
– PCI distal RCA, ostial IM
• 2008:
– RIMA LAD
• 2 years h/o increasing SOB – stable angina
• TH SCAN: – severe inferolateral reversible defect
• LHC: – Patent RIMA
– Patent IM stent
– Long heavily calcified proximal mid RCA CTO
– Bridging collaterals – small epicardial collateral from CX
PRE
TURNPIKE SPIRAL – MIRACLE 6 –unable to cross CONFIANZA PRO 12 proximal cap
DEESCALATION MIRACLE 6 PILOT 200
GAIA II
BIG HEMATOMA
FIELDER XT - KNUCKLE
MIRACLE 12 STING RAY BALLOON
STING RAY BALLOON COAXIAL
STING RAY WIRE various attempts
PILOT 200 various attempts
PILOT 200 distally BHW distally
FINAL
CASE 3GRAFT FAILURE - PCI OF NATIVE
DISEASE
• HEAVILY CALCIFIED LESIONS-increased use of Rotablation
63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
Severe LMS – prox LAD calcified disease Blocked LIMA
63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
Rota 1.25 mm Rota 1.5 mm
63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
FINAL 1 FINAL 2
63 male – CABG x3 – blocked grafts –heavily calcified extremely tortuous
superdominant RCA
MOTHER IN CHILD IN GRAND CHILD TECHNIQUE
6 FR GUIDEZILLA INSIDE 8 FR GUIDEZILLA
ADVANCE THE SYSTEM AS A WHOLE UNIT
MOTHER IN CHILD IN GRAND CHILD TECHNIQUE
6 FR GUIDEZILLA INSIDE 8 FR GUIDEZILLA 1.5 mm balloon cannot cross
ROTAWIREROTA 1.25 MM difficult to negotiate the bend
ROTA 1.25 mm 140000 rpm ROTA 1.25 mm 180000 rpm
ROTA 1.5 mm ROTA 2.0 mm
Post rotaMOTHER in CHILD in GRANDCHILD with balloon anchoring
MOTHER in CHILD in GRANDCHILD STENT CROSSING
63 male – CABG x3 – blocked grafts –heavy calcification of native vessels
FINAL RESULT
In Conclusion…
• Various challenges post CABG
• Require expertise in:
– Various CTO techniques
– Rotablation
– Complex high risk PCI
Rotablation in the extremies: Mechanical support assisted
unprotected left main stem rotationalatherectomy
Petros Dardas, MD, FESC
St Luke’s Hospital
Thessaloniki, GREECE
History
Past medical history• Male 61 years old,
hypertensive, non diabetic with moderate kidney disease
• 1997 Aortic Valve replacement- metallic (bicuspid aortic stenosis)
• 1997 Valvular Heart Failure (EF=35%)
• 2009 PCI Left Anterior Descending
• 2011 ICD implantation for primary prevention (EF=25%)
Cause of hospitalization
• Heart Failure Decompensation: peripheral edema + dyspnoea
• Electrical Storm: 3 ICD therapies for VF
• ECHOCARDIOGRAPHY:
– EF=15%
– Metallic Aortic Valve: normal function
– Mitral Valve: moderate to severe regurgitation
EF=15%
CORONARY ANGIOGRAPHYRCA: normal AVR: normal
CORONARY ANGIOGRAPHYsevere heavily calcified distal LMS ostial LAD ostial CX (MEDINA
1,1,1)
Coronary angiography
• OPTIONS:– CABG – declined by surgeons
STS score >10– PCI – Rotablation without
support– PCI – Rotablation with
mechanical support
• DECISION– PCI – Rotablation with
mechanical support– IABP: Inadequate support– IMPELLA: Non applicable (AVR)
ECMO
ECMO
• Percutaneous femoral cannulation of both the common femoral vein (24 Fr cannula) and artery (18 Fr cannula with added distal leg perfusion branch)
• the circuit was connected to a third generation (magnetically levitated) centrifugal pump (Centrimag, Levitronix) and to a long term (low pressure) membrane oxygenator (Medtronic)
• cardiopulmonary support with flows up to
5.5 l/min
PILOT 50 LAD - FINECROSS IVUS CANNOT CROSS
PTCA: Rotablation LAD, CX, CULOTTE technique
ROTAWIRE THROUGH FINECROSS ROTABURR 1.25mm 140000rpm
PTCA: Rotablation LAD, CX, CULOTTE technique
ROTABURR 1.5mm 140000rpm POST ROTA LAD
PTCA: Rotablation LAD, CX, CULOTTE technique
ROTABURR 1.5 mm CX 140000rpm POST ROTA CX
PTCA: Rotablation LAD, CX, CULOTTE technique
STENT LAD DEPLOYED FINAL KISSING
PTCA: Rotablation LAD, CX, CULOTTE technique
PTCA: Rotablation LAD, CX, CULOTTE technique
• FINAL POT 4.5 BALLOON 26 Atm
PTCA: Rotablation LAD, CX, CULOTTE techniqueFINAL RESULT
PTCA: Rotablation LAD, CX, CULOTTE techniqueFINAL IVUS RESULT
• Day 1: patient completely dependent on ECMO –pressure tracing direct line – iv inotropes
• Day 5: ECMO removed – full recovery
• Day 8: patient discharged – NYHA I – EF 35%
• Mitral Regurgitation improved grade II
PRE 15% POST 35%
EF
Conclusions (I)
• High Risk PCI is feasible if facilitated by Mechanical Circulatory Support
• IABP remains the old fashioned gold-standard• ECMO is indicated for life threatening pulmonary
or cardiac failure, when any other forms of treatment have been failed
• ECMO provides full hemodynamic support although at the expense of a higher complication rate due to the increased invasiveness of the procedure in the femoral vessels and the presence of an oxygenator which increases the inflammatory response
Conclusions (II)
• Identification of high risk patients who most likely will benefit from Mechanical Circulatory Support is crucial
• Type of Mechanical Circulatory Support depends on:
– Left Ventricular - circulatory status
– type and duration of procedure» rotablation in heavily calcified tandem lesions, where any
other method of percutaneous intervention would have failed with detrimental effect for these particular patients