Thank you so much George, dear colleagues, really a pleasure to be here. You forgot something, I was your ex-fellow at CIF as well. And I think I have to congratulate Carlos for this great presentation. This is a 79-year-old gentleman, past medical history, hypertension, diabetes, former smoker, peripheral artery disease, and a low-risk myelodysplastic syndrome. And his past medical history, about 20 years ago, had ACS with angioplasty to right coronary and LAD. This patient presented for us, this was just a week ago, so I learned this with Antonio Colombo, should always have you know the cases you are doing their practice. He presented with typical chest pain, troponin level in the rise, more than 4000, and ECG, does a right bundle point block, so he was diagnosed with anonasty elevation acute myelodysplastic syndrome, and he became stable at the time, you can see here this EKG. This medication, he was at the time of his admission, some anemia, normal creatinine levels, he performed ECHO with a 45% EF, with some akinetic segments in apex, in apical segment anterior wall, and also the basal segment of the inferior infraceptor walls. And also, there was evidence, also aortic valve disease, with AV area of 1.4 cm2. So he underwent the diagnostic cath, as you can see his RCA, there is a proximal patent, and what appears to be very severe, tight calcified stenosis in the distal portion, with some diffuse disease in the distal branches. Same here, we can see a more sub-occlusive stenosis, heavily calcified, in this distal segment pointed by the arrow, and now in the left main, heavily calcified disease, involving the bifurcation, a diffuse disease, circumflex, as well as the LAD, that's a standard portion of the LAD, which was a patent, but here you can see a more acute angulation, here the take-off, very centric calcified lesion, in this LAO cranial view, it's very clear that both osteons are evenly compromised, and here in the spider view, you can see this very severe disease also extends for the proximal LAD. His left ventriculogram, basically showing what has been described in his echo, and also, to add here, it was very difficult, the first attempt was to go radial, we could not, I wasn't in this diagnostic moment, but the operators could not advance, so they ended up trying the femoral, you can see the femoral, right femoral, and iliac, heavily calcified, you know, really, really, they could not advance here, and despite this severe disease in the left side as well, they ended up advancing a little bit upper, right here, but that's how they managed to do the exam. So how would you treat this patient? Maybe we can stop here, George? Yeah, that's great. Let's start from Tanvir this time, Tanvir, very experienced with the difficult cases in Emory, as well as through all the webinars of SCI and before, the bifurcation clubs and so on, what do you think? You know, the thing is that this very severe calcifying multiversal disease, I would like to know what the EF and the EGP are like, okay, certainly you, as we've discussed in the previous case, you want to have protection of the right before you do a complex left main, but if you were to ignore the right completely and you were to worry about the left system, it will require significant plaque modification, which means arthrectomy plus-minus shock wave, and if you're going to do that, I would really like to know what the EF is like. Now, you've shown me that the femorals are not the greatest, so I don't know if the EDP is high and the EF is low, whether you have options for a transceival impella or not in this kind of case. So I think before we're going to pause and think and sit back, you haven't told me, I know you have comorbidities, but this is the kind of case I would also show the surgeon to see if there's a surgical option or not, because whatever you do with either of those vessels, there is a high chance of re-stenosis. So a surgical option is reasonable, if they decline, I would have to worry about which is the best shot I can give. If I worry too much about the right, can I do the left side alone, but that would require support for the reasons I've told you. But would you go through the bioprosthetic ABR with the impella? Why not? I mean, you can do that, sure you can do that. I mean, I don't know, we don't really typically do that at our center, we would do this probably with a balloon pump and just very short, fast runs, aminophilin with a pacer on standby if we need. We do have done that over here, in many cases, quite comfortably. Yeah, no, I think we could probably put the, how old is the bioprosthetic valve? No, that's actually a native valve, it's an AS with a native valve, 1.4. Oh, an AS with a native valve, okay, but how tight is it, I'm sorry? 1.4, 1.4 moderate, yeah. I think we can probably do that, yeah. I think it's borderline, yeah, we could definitely do that, yeah. I mean, I'm very concerned, though, with this kind of access, where are you going to put the impella on it? That's another practical thing, I mean, these groins with the common femoral calcification, I mean, that's really a scenario here that's very tough. Unless you know how to do a transcendental access, that's the other option, I'll put it trans-axillary impella, that's the other option. Oh, definitely trans-axillary, yeah, we could do that. Let me remind the audience that we have, they can also post questions through the chat or anyone, and I monitor that. Well, it's interesting that I think even a bigger size sheath here might be a concern. So, the first question is, what's the access? What's the access that allows a 7-frame sheath or an 8-frame sheath in order to do at least some of that? I don't know that reliably you can do an impella, maybe, I don't know, maybe you have to do an endarterectomy and have a vascular surgeon pass the impella on the left femoral. Or you can shock with the left groin. You shock with the left groin and see if you can pass an impella. That's the other thing. You take a prayerful shock, let me see if it can go up. Right, I think the left CFA has, you know, above the calcification, I think there is a zone that potentially could be safely accessed. I don't know about impella, but we could definitely put a, you know, 7-frame sheath if needed. But I would definitely get a right heart cath, and as Dr. Rob was mentioning, get an EDP and a right heart cath to make sure that, you know, if EDP is normal and right heart numbers look okay, then I would be a little bit, you know, more cavalier in doing it without support. Or otherwise, the options that you guys mentioned, either, you know, go transcable or transaxillary if needed. Also, I don't know about your guys' preference, but I think if, you know, if we don't necessarily, we don't maybe not necessarily need impella if you're going to do shockwave versus if we do rota, then I think we'll for sure need impella even if the, you know, even if the numbers are borderline because I feel like many a times patients don't tolerate, you know, dual rota in the left main. Asma, you're a vascular expert. Don't you think the short gastric segment in the left femur can be treated by shockwave and make a move up from there? Don't you think so? Definitely. But yeah, I mean then you would have to, can you go back to the image of the left groin please? Yeah. Of the left groin, yeah. The other one. The left one. Yeah. This one is a disaster. Yeah. See, exactly. That's, yeah. Then you'll have to access, where would you access to treat it? Then you have to, you know, maybe, then that's another issue. You know, where would you, you'd first have to, you know, the contralateral access looks pretty bad. Then, you know, maybe you have to go either, I don't think we have shockwaves that long that we could go radial and treat it. So, my concern is that that would also in itself pose a risk unless you want to access CSFA and, you know, then treat it that way. But you won't have that much, you know, you'll only have a very small working length. So, that would be a problem. Like, I would prefer, you know, X-ray or trans-cable if your center does it. Yeah. Okay. Okay. All right. Let's see. Let's see how things go. We have a discussion. Go ahead. Go ahead. Five minutes for this case. Ricardo, march ahead. So, just to help us, so the risk score here, Syntex 1, 33. We're going to go for Syntex 2 with all this, you know, disease everywhere. So, it does recommend PCI. Error score above 6%, STS about 4.5%, and also a very high score for bleeding as well, the precise depth. So, it all poses a lot of, you know, concerns here. The heart team was discussing this case and ended up, you know, due to the high risk of surgery as well, decided to go for PCI. And some of what has been discussed here to try to get some support and, you know, in the best and the safest way possible. So, which best strategy? I think, you know, we can just pass and maybe live to the end. So, the patient was referred. This was just a week ago. So, that day, he was referred to the ICU. He was proposed to undergo PCI the next day. But during the night, patient developed refractory chest pain, dynamic change in EKG, circumferential ischemia, and evolved with clinical or dynamic instability. So, it was called like 4 in the morning. This was his EKG, and he was already under vasoactive drugs. So, basically, when we first got here, that's what we had. And we could cross with wires, you know, in both branches, LED and circumflex. This is a 2.0 non-compliant balloon. And we went high pressure just to open, you know, the way here. We tried to go with the 3.0 by 15 to open the proximal LED. We couldn't open the vessel here. And then, that's when, you know, his condition become more critical. And we ended up, you know, doing rotablation here. That's what we had on place. And it took like four attempts here to go through. And after that, we didn't have time, you know, to put a micro catheter. So, we had to remove the wire from the circumflex and then went back. And then do a more aggressive lesion preparation here. And we, due to the situation, we said, well, let's just, you know, keep the left main and the LED first. And then we deal with the circumflex. And we don't want to do more than we need here. And this was all the lesion preparation with non-compliant balloons. And we had a E.A.V. stand, 3.0 by 28 deployed, just at the level of that bifurcation, proximal bifurcation. And then, Ivos, thank you, Professor Rapp, for sharing this slide. Very pleased, you know, to share that today has been published the American Guidelines with 1A recommendation for patients with ACS undergoing left main stem implantation or complex lesions, intracoronary imaging, IVOS or OCT, is recommended to guide the procedure. So, this is wonderful. And that's based on very robust data that we have been seeing recently. And this is the IVOS. I'm going to go here more quickly, just for the sake of the title. Of course, the diffuse disease vessel here. But, you know, there we started the distal stand. And here, that's the stand deployed. That's definitely room here for some optimization, heavily calcified, as you imagine. And as we come here, we haven't done yet the POT. So, you can see the whole incomplete position. We just want to make sure that we are doing the right thing here. And the right sizing. So, it's a 4.5 vessel. And we stopped just at the level of the osteon of the left main. So, we're pleased with this positioning. So, POT coming to the osteon of the left main with a 4.5 non-compliant balloon. Easy to recross to the circumflex. And then, we have individual dilatations here. And then, we had the report. And then, we went back to the proximal part of the LED. Now, not involving the bifurcation. And we had a final IVOS. And again, I'm going to go more quickly here. So, you see a much better and well-expanded proximal LED vessel. Despite the calcification. Now, as the circumflex comes. We can see here. The circumflex just came here. So, you see fully opposed. Optimally, the whole position is turned into the left main. Just going up to the osteon. And this is the final angios. We did provisional. Circumflex was okay. Timid reflow. No dissection. There's some disease there. But for us, Kissy Balloon was enough there. And here, in the spider view. We are very comfortable and pleased with this result. Which was confirmed by IVOS. So, how it has evolved. Hemodynamically became stable in the ICU. Even though he was under vasoactive drugs. Adrenaline and butamine for the first hours. And then, he presented with episodic atrial fibrillation. With reverberative response. Which was treated with Imidaron. And was back to normal. And out of vasoactive drugs yesterday. Lactate would rise under this situation. Back to normal. And he's planned for tomorrow. To come just for the regular room. And hopefully, he's going to go home. In the early next week. So, thank you so much for your attention. And this was really a case performed last week. I know. Terrific. I'm amazed we could do it without support. I know. That's very good. How frequently did you use George and Ram? Impella or support? PCI in case like this? Left main for instance. How frequently? I would have called the vascular surgeon. Cut down on the left side. And pass Impella. I mean left femoral. In all your left main cases? No. This calcification is exactly. At the middle of the common femoral. So, you're going to put a 13 front sheath above. It's just too high. High you want to close. You want to put it below. You cannot pass. You don't even have any access to do the. There's no access to do the. Whatever you want to do. Or the blade or the leg. Or the IBL or whatever you imagine. So, essentially he's got to cut it out. And you know. Then you pass Impella. And then you also close in the end. And then you do single access through the Impella? Yeah. Exactly. So, have a facilitated access that way. Something's got to give here. It's just a lot of scenarios. To be given. I was just going to say. What we have in place. There's no Impella available. And we are very concerned. Of course about the access. And things were deteriorating. So, you know. Luckily, you know. We could have the left groin. Based at the same level. And we were lucky. You know that. It was a blast. The patient could respond. But without a vascular surgeon. Really, really impossible to have a MCS there. Yeah. No question about it. Yes. And of course the problem with the balloon pump was that. Where is the second access? You barely have one access. And you know. That's just a very, very, very difficult case. I think the access is the number one case in this. Alright. Let's move now. From Brazil. A bit down south. To Buenos Aires, Argentina. My friend Alfredo Rodriguez. I know for many years. Many decades. Alfredo. Originally sanatorio Otamendi. And a major leader. Of international cardiology. In South America. And of course in his own country. Argentina. Thank you George. You are very young. Not like me. Did you share my slides? No. Yeah, you need to do so Dr. Rodriguez. There is a button there. Right in the middle. Usually it's yellow. It's green. And you just push that. Or click on that. Do you want to answer the question in the chat? While we're loading up? It was asking about the last case. For left radial access. Was there a possibility? Yeah. It was a possibility. From the left groin. And we had so much difficulty. In the right radial. We said, you know what? Let's just try something that had already worked. Luckily it went well. Yeah. I was actually thinking the same thing. Because left radial. You could have easily. I mean for what's worth. Left radial is my default radial. Access option. So yeah. But again. In this situation. You may need a San Frans device. And a 6 might not fit. The guy has perivascular disease. The person has perivascular disease. Even if you get the access. You're going to be comfortable to upgrade. In such a case. To a San Frans radial. I don't know. So of course. If we manage to go to balloon pump. You can put the balloon pump on the femoral. Thanks for watching.

acute coronary syndrome

Percutaneous Coronary Intervention

intravascular imaging

rotational atherectomy

cardiovascular imaging