All right. Thank you, everybody, for having me. It's an honor and a privilege to get to present a case and have a discussion with such an accomplished group. So the case we're discussing today, the background is we have a 68-year-old female with a history of coronary disease with a remote PCI in Iran years ago and then a somewhat recent PCI at an outside hospital October of 2022, presented with recurrent heart failure emissions and then unstable angina. For her PCI history, she's got a remote history of a PCI with times four in Iran and then unknown stent sizes of locations from that. And then recently at an outside facility, had a left-main-to-circ stent in October with a 2.75 by 38 onyx, and then an osteo-RCA stent with a 3.5 by 38 onyx, and then relevant history is hypertension, CKD stage 3, and tobacco abuse. She had some cardiac diagnostics done when she got admitted for, I believe, the third time in three months with heart failure. TTE performed showed that an EF was 15% and she had severe MR. We did a right heart cath at the time of our diagnostic angiogram with the numbers shown below that were most notable for, you know, moderate pulmonary hypertension that's post-capillary in the setting of an elevated wedge of 28, and cardiogenic shock with an index by FICC of 1.6. Here's her diagnostic angiogram. So, I'll pause here before we get going on what we did next. We stopped at this point on the diagnostic day, admitted her to the heart failure service for optimization and discussion about what we thought was the best plan to approach here, but I'm curious, you know, we got multivessel disease, very high risk patient with a low EF, severe MR, you know, how would you approach this? What vessel would you tackle first? What would be your approach in terms of support and no support? I'm just curious what the group's thoughts would be on this. Dr. Sharma? Yeah. So, I'm in line with the very interesting case, and knowing that probably at what, six, five or six interventions, I'm sure the LAD had multilayer in some area, but it almost goes up to the apex, becomes subtotal, and with this condition, I mean, I would, if Impella is available, I think we'll take Impella and probably do the RC approximately first, with a short segment. The LAD will require a lot of work, and we will do rotation, the LAD is such a diffuse disease using a 1.5 bar. I know there is a question of more slow flow, but otherwise, no matter what you do, you'll not be able to squeeze all the intimal hyperplasia, and that, I would try to do both of them, although there is a lot of data people believe is the cardiogenic shock into a culprit vessel, but I think it will be very tough to say what the culprit is in this particular case, in this shock situation. There is, although RCA is about 90, 80, 90, approximately short segment, LAD is diffused subtotal, maybe that may likely is the culprit, but both could be culprit in this particular case, knowing that LAD has very little blood flow at present. Do you have any perfusion study or viability study on that patient before we do the intervention, Brian? We did not have any, like, MRI viability or anything. She had an echo, and it was, you know, diffuse kind of global hypokinesis, but every segment from what we could tell on the echo did look like it was moving to some, they were all equally hypokinetic. There was no particular akinetic portion, no aneurysm, no LV thrombus. I will say that while she was getting optimized between the diagnostic cath and the intervention, we did get a CTA of the legs because, as you guys pointed out, we were thinking about Impella support, and unfortunately, she had pretty bad iliofemoral disease that was not amenable to an Impella insertion either, unfortunately. Ron, at your center, you know you like optimization, and do you use less Impella since you published that paper, or about the same, or do you use it for this situation? We try to use it wisely. We don't have anything against Impella. Impella is a great device, but I think sometimes it's overused, sometimes it's underused, so we just try to use it when it's needed. My issue with this case, frankly, when I look at this LAD, if you want to show us back, just go one or two shots backward. It is really, look to me, like, I'm not sure we can really keep that artery open, even if you're going to recanalize it. Look at the distal disease of the vessel. I mean, it's not just instant tristenosis. There's really nothing going on there, and I can tell you, these are the cases when they send them to me for brachytherapy, I'm actually reluctant to do it because I said, look, if I don't have a good flow distally, the likelihood that this artery will stay open, even with brachytherapy, is not that great, so to me, the most important thing, and that's why I deferred it to Dr. Sharma, show me that you can get a very good flow down the road, because if it's not, and this is just diffuse vessel disease, I would just focus on the right that would leave the LAD, and I will try to treat the LAD medically, because I don't think you can fix it. The question also, what's happening with that bifurcation, you may want to salvage the diagonal. That diagonal seems to be more hopeful than this LAD, but again, going after that LAD and compromising more the diagonal, without any good distal flow, I don't know. But could it be that, remember, such a tight lesion in the left main to austral LAD, and then whatever diagonal, ramus, or proximal, maybe if you open at that area, and of course, you cannot compromise any vessel, you have to have wire in the side branch, make sure you're opening the side branch also, so that we'll be start seeing some blood flow in the apex. Take the inverted mustache, in the lower segment, just by opening it, would you improve some blood flow, and you start seeing the vessel, but yeah, the long-term, no matter what we do acutely, the long-term patency of this LAD is dismal. Yeah. Go ahead. Yeah, just for the sake of discussion, I mean, this is a terrible case. So, it's severe leventiculitis dysfunction, 15%, severe 3-phase synthesis, I mean, it's a full beta jacket in the LAD, in the right coronary artery, all these PCIs, so I don't think this is a case for cabbage. I mean, I don't see the distal LAD, circumflex is also very tiny, the posterior descending was not so bad, but I think the first thing we need to do in these cases is make sure what is the mechanism of mitral regurgitation, and make sure that there is no cabbage. I think there is no cabbage in these cases, and then we need to proceed. And I think even though the LAD distal flow is very poor, or basically the vessel is occluded, I think you need to offer anything possible. And then I will use an impella, and I will go, I don't know, first perhaps the left main, and then the right, or going to the right with the idea that this is going to be easier, and then you will address the left main with the open right, perhaps this will be more secure. Yeah, but this patient cannot have an impella, so you can use a balloon pump maybe, or you can use impella from the axillary, but I assume there is a disease as well there. So, maybe we'll hear from Dr. Kearney, what would you do in Washington University? Yeah, I think just to echo your comments that when the stented segment gets to the distal part of the vessel, those are the ones I'm not sure I can salvage, so I want heart failure to see them and look at that, if that seems to be a big part of her presentation. But I think optimizing the CERC and bailing out any of the side branches there would be kind of our biggest priority, just because I'm not sure about the durability of this, and see what we can get. We've also, I think, scaled back quite a bit on our impella use in people who are pretty stable, but it's really hemodynamic dependent, I think, whether to put a pump of some form in there. If all you have is a balloon pump, I am more likely to do that up front, though, than kind of wait until they get sick. Yeah, as we discuss this, I'm getting more convinced maybe to fix the left man into the circumflex. It may be one of the mechanisms for the MR, but this LAD is, as they say in Europe, kaput. But Brian, why don't you continue? We gave you a lot of thoughts, and we have to make sure we're on time. It's a great conversation, because it's very similar to the one that we had. I think we felt that we had to offer some things here. We felt that there was no cabbage candidate with no distal vessel that we could see. We had a lot of debate with the apical LAD. Is it so diffusely diseased, or is it just an inflow issue that's making the outflow look worse? We went back and forth about which vessel to fix first, and we ultimately felt that the RCA being a more straightforward lesion, we should try to fix that first, and then try to tackle the LAD. We brought her back. The RCA was actually a fairly straightforward lesion to wire, so we wired and swapped out for a wiggle support, and did an IVUS that showed it to be closer to a 4-0 vessel. It actually gave fairly straightforward, which is balloony angioplasty. There was only one layer of stent in the RCA at that point, so we did electrostent with a 4-0 on extent. I know that she had a recent 3-5 to the proximal RCA, but it looked like that was uncovered initially because there was only one layer that we saw in our IVUS interrogation. This is the result that we got in the RCA. Again, I know that's not the bifurcation lesion. It was the more straightforward one, but it's the one that we at least tackled first for her. Then I'll show an IVUS pullback here of what we saw in the RCA after we stented. There was a question from the chat about transplant. I don't think that this is a good candidate for transplant, given her age. We were happy with the result in the RCA, at least at this point. I know it's going dark here as we pull back into the guide. We were happy with that, so then we moved on pretty quick to the bifurcation, which was the real complicated lesion to address here. We went up and were actually able to wire the LAD pretty straightforward, the Whisper wire, but the CERC proved to be a very, very difficult wire job. We actually were unable to wire it, despite spending a long amount of time and a lot of wires. We started with the Whisper. We tried a Mongo, a Pilot 200, a Fielder XT, and then eventually a Confianza Pro 12. Despite all of those, we weren't really able to wire the CERC. You see here's our Confianza, which is able to actually get somewhere, but it's clearly not actually in the stent or in the vessel itself. I guess I'll pause at this point and ask the group, this situation, how do you guys proceed when you're at a tough bifurcation in stent and you can't really get one of the branches wired? Dr. Sharma. No, I think many times it will happen that now you're trying to get a wire, maybe it's not going exactly in the circumflex. This concept that there is a subtotal, you had tried everything. I will still try to open the LAD and retry. Yeah. So, if you change the anatomy of the struts, you may create ... Remember, that's why we're doing POD. We're doing a lot of POD because we want to have a good access. So I wouldn't give away, I would agree with Dr. Sharma, I would try to at least change somewhat in the anatomy of the stents. But again, there is a risk, Dr. Sharma, that we're going to lose that circumflex, it would be completely occluded. My feeling is that the problem that you cannot cross is not because of a lesion, but because of the configuration of the metal. And again, I don't know what was the technique that was used before, coulade, decay crush. I'm always worried about decay crush because there is the nose and they're hard to recross sometimes. But Dr. Alfonso, what would you do? Yeah. I mean, if there is no other option. I mean, if it's impossible to cross the CERC, then, well, somebody could say, well, in order to avoid complete blockage of the CERC, an ablation technique in this case could in theory, you know, there's no POE effect or whatever. But I don't know. I think I will go with a small balloon and try to change the anatomy of this bifurcation and try again before a final device in the LED, try again the CERC. Brian, those are all great points, and it's ultimately what we decided to do. We decided to try to change the anatomy, knowing that if we balloon, maybe it makes it better, maybe it makes it worse, but we tried everything we could think of, and nothing was going. So we took a 2-5 balloon into the LAD, and were not able to dilate it, actually. There was a pretty big waste on it, and so given that, we decided to do rotational atherectomy into the LAD, because there was not expanding waste on our 2-5 balloon, which is clearly too small. So we took a 1-5 burr, did rota into the LAD, hoping it would allow our balloons to expand, maybe change the anatomy, and so after we did our atherectomy run, here's what we got after atherectomy. And you see that we're losing the circ with slow flow, and you know, it's getting worse. So any thoughts on how we would tackle this problem? No, I think what you did now, earlier you could not open the lesion, go back with that balloon. Maybe I'll use a cutting balloon here, at 3.0 or 3.5, and try to open, maximize, because we still have to work with that circ. Now, during this time, I know patient has no other hemodynamic support. What is the hemodynamics going on? How things are? So we were actually a little surprised she was tolerating this okay. We thought she'd get pretty sick as she was kind of hanging by threads in terms of coronaries before we even started. I don't know if it was maybe fixing the RCA that gave her some degree of tolerance to this, but she wasn't, you know, crumping, at least on us on the table. We had some time to try some things and balloons and wires, at least at this point. So I think then now you go, I would say that we go back and open that area once again, and then come back with the, you know, a lot of people talk about the twin pass or bring a supercross 120 and just trying to make more focused entry of the circumflex, but I still, now we have both decreased flow in the circ and also in the LEDs has opened a little bit, but now hopefully your balloon will open that up, because you use a 1.5 bar. Yeah, you want to salvage a circ if you can. So I think that I would try to rewire it again, and maybe we will be lucky this time. Okay, tell us what you wrote. So those are all good points. And initially we tried to wire it. And again, we're getting outside the vessels here, outside the stent architecture. So we did exactly what you guys were talking about. We said, we've wrote it. Maybe we can now actually expand some balloons and change the anatomy a bit. We took a 3.0 balloon and then ultimately a 3.5 Wolverine cutting balloon to try to make some fenestrations and flaps that would be amenable to us trying to get a wire down. And then we went back and you see there, it's not as good as it was in the beginning, but we got some flow back here. Very good. It goes better now, yeah. Exactly. And so we said, let's try some more wiring at this point and see what we're able to get down. And it took a good amount of time and a lot of wiring, but ultimately, eventually a Pilot 200 was able to get down into the circumflex. Beautiful. So we used our micro catheter to exchange for a workhorse wire, and then we're able to start doing some stuff here and we're kind of in business. So how would you guys tackle addressing this instant restenosis now that we're, an hour into the case and finally have a wire down the vessel? Now we're going to the therapy. And I think, again, it's going to be a challenge to put here brachytherapy catheter, but again, those centers, they have it. I would still give it a chance because I think maybe now that you did a good dilation before it's restenosed again, that would be my first choice. My question to you, Dr. Alfonso, is dry-coated balloon, when you go through bifurcation, are you afraid that the coating will be shaved from the balloon? I mean, we always have this concern. I think, again, it's very important to dilate things properly, sometimes using a guy liner or extension catheter to make sure that you will be able to get as close to the lesion as possible. And in this situation, there is some controversy among the experts. Some people like to use, in this case, like two dry-coated balloons, like a kissing with that. Other experts, like Bruno Schiller, say that this should never be done. I don't know. I mean, one way or the other, I would use dry-coated balloons, plakitexel dry-coated balloon in the two vessels after the best dilatation I can do. Dr. Carney, would you go with the third stent into the circumflex, giving the fact that LAD is a lost cause anyway over time, and try just to salvage it with a good stenting lift man into the circumflex, or you would do something else? No, I think she's proven that more stents aren't the answer here. And in a lot of these cases, after the third layer, it's like the last-ditch effort. And without another parachute, like transplant or something in her, I wouldn't entertain that. I think, like you, it's worth a shot for these other alternative therapies. Yeah, no, I agree with you. If there is one thing that I learned, more stents doesn't help. I mean, they actually... But the question, again, that I think is important before you start a case like that, Brian, is to understand what is the viability of the anterior wall. Because if there is no viability, I wouldn't mind at all about that LAD and just focus. I would look at this. This is like a vessel that was grafted by Lima. It's going to a dead tissue. There is no point to fight on the LAD. The circumflex, however, seems to be more worth fighting. But a functionality test would help. One comment on the balloon pump impella. I'm always amazed how many patients who have chronic ischemia or chronic disease tolerate well the procedures, sometimes with a little bit help of liver, norepi. But most of them, they do not need any support. I mean, the question is, we usually get in trouble in patients that are not used to that kind of an ischemia. And also, one thing that can help you, if you would have done a right heart cath, or if you had the LVEDP on this patient, if it's a low LVEDP, I think it's going to be, again, more forgiving than very high LVEDP. But we have more questions from the chat. So, John, do you want to tell us what the questions are? Well, you had the LVEDP. LVEDP was quite high. Your wedge pressure was 30, right? Yeah, it was in the mid-20s. I believe that was Thursday or something like that. And we let her get cleaned up by heart failure and then brought her back early the next week to do the procedure. And I'll be honest, I don't remember off the top of my head if we dropped into the ventricle. I would be surprised if we didn't. No, you did the ventriculogram. No, you had the ventriculogram here. John, any questions? There is a delay. Dr. Sharma, the ventriculogram was from about a week earlier. So I think that is one of the questions that we have here is, just from a clinical judgment standpoint, this was an outpatient that presented with subacutely worsening symptoms and then has the right heart catheter consistent with cardiogenic shock. Is this a case that anyone on the panel would do right then? Or would you admit the patient and optimize them and then evaluate for mechanical support options? And then the second question is, one of the panelists did, was imaging performed? And I know Brian showed that one IVAS round that showed a combination of stent under expansion and neoartherosclerosis. So could the comment panel at your institution, what imaging modality are you choosing to use to assess the mechanism of ISR, be it IVAS, high-definition IVAS, or OCT? Well, I think all of them as good as they get you the answer. And I think that, again, OCT may give you a little bit more information. Left main OCT is a little bit more problematic, but OCT lesions are problematic. But I think, again, do whatever you do and you can get the catheter in and the image will give you enough answer in terms of the mechanism. Is it tissue? Is it mechanical? Is it under expansion, et cetera, et cetera. So that's what I would do for the imaging. With respect to treatment, any vessel during the shock, again, I will refer it to Dr. Sharma. What would you do when you have the patient in shock? This is not an acute MI. I mean, this is a kind of progression of disease, probably of ISR. I didn't see any clots here. Would you intervene at the time of the shock in any of the branches? So I think that's why I mentioned earlier that the culprit vessel concept of the shock, I think that probably for more so is a truly STEMI type of patient has total occlusion of the one vessel. Now you're going after 80%, 90% vessel and creating some extra injury, and that has been harmful. So this kind of case where there's no true culprit vessel could be more than one. I would probably do both at the same sitting. I know that there was no impella, but whether you can put a balloon pump, sometimes that is possible. And if there is a chance for optimization, we think that patient is not that sick. Knowing that biggest problem with the cardiogenic shock will be that you had to do some integrated blood flow to stabilize the condition. We can give pressures, we can give diuretic, but some integrated blood flow, if truly cardiogenic shock, even in the chronic cardiogenic shock, it's not acute which you're feeling that you need to optimize medical therapy and acute you definitely, that some blood flow restoration will be required. Now, if I'm doing RCA, just a little bit of better hemodynamic, probably okay. Let's bring the left system a little later. There's nothing wrong because as you saw, I'm sure it took a few hours on the left side. More we are, more procedural, all that die, all the basically trauma to the vessel that continues to create more problem. But yes, goal should be that we are coming out here without putting any additional stand, particularly on the left side, maybe some focal area, which we need to do, but otherwise you, and then can you use a drug coated balloon or not in America, but outside, yeah. So we're coming to the end of the hour. I just like every one of you to say in 15 seconds, what is the lessons that you take from this session bifurcation instant restenosis? I'm going to start with Dr. Alfonso. Well, quickly, I mean, this is not an easy pathology to treat. In America, you got this 10% and we got 5% of our procedures. These are unique extreme cases, even though with all the knowledge and all the armamentarium, sometimes they keep coming back and we need to keep learning. Thank you, Dr. Sharma. I will say that I know people are worried about rotation arthritomy, both those cases of Kathleen and Brian, I would have done start with arthritomy, which I said before during the case, ultimately ended up in using this LED anyway. So key is that yes, appropriately now, I would say that if you can get IVL balloon, there's no question you avoid the arthritomy. But if you know that IVL balloon will not go into the job, arthritomy plus minus IVL. Kathleen. Yeah, I think both of these highlight how the tools we have are more effective with fewer layers of stent, not more. And so I think really focusing on using that the first time the patient presents with ISR, which you didn't have opportunity here, but I think we can get much more effective and durable results. John Liskow. Thanks, Dr. Waxman. I think one of the things that I've taken out looking at all these cases that you see some world-class operators with the best tools available, still struggling to get great results and still having a lot of questions. So I think on the index PCI, having a meticulous result and focusing on imaging and doing it right the first time so you don't have to run into the problem is my take home. Thank you. And I'm going to hand to Dr. Rapp to finalize and summarize the session. Thank you very much. Thank you very much for the panel and the case presenters. Great cases. This is a vexing problem. We may not have all the solution, but one thing about bifurcations, know your techniques and do it right and don't avoid the steps, okay? And use imaging efficiently. And I cannot say more than that, that imaging is key and the first intervention for bifurcation is key. Do the steps right if you're doing two-stem technique. Don't skip any layers. You've got to do it right. If you do it right, the chance of the patient sharing back is low. We all see in both these cases, we didn't know what kind of technology or technique was used and maybe the operators did not follow what we would currently do in practice of bifurcation stenting. But the question for all of you is this, with Brian's case, what would you do if this patient came back? What do you do again? I mean, what do you do with this patient? And that's the question that's hung over me since Brian is in this case. Anyone, a few? Well, if you ask me, I would do brachytherapy to the limb, to the circumflex. I would do actually, I won't wait until it reached the nose. I will call the patient in another session, maybe a week after the recanalization, let him rest, enjoy a little bit perfusion, do a brachytherapy at least to the left and to the circumflex. I don't mind to do bifurcation to the LAD if this helps. I don't think there is anything to lose there. With respect to the right, we can give a chance. It's the first DES, second DES. But I think you're not done yet because if you're not going to do anything, guarantee you're going to see that patient coming back with even more severe risk to noses. Well, thank you everybody for a delightful session. It's really, very, very good. And I hope it helps our audience in these tough cases which are really difficult to evaluate and take care of even with white experts. We all have different opinions, but these are really great tough cases. Thank you very much for participating.

68-year-old female

coronary disease

heart failure

unstable angina

percutaneous coronary intervention

multiple vessel disease