I think we all know that acute corneal syndrome with left main is associated with a very high mortality. Traditionally, you know, left main disease, historically it has been surgical disease, but I think, you know, the people on this call and the panel know that we could treat these patients safely now with robust devices that have allowed us kind of to do these more complex procedures safely. I think it's fair to say that for contemporary interventional cardiologists taking call, that having the skills to use advanced mechanical support devices, do atherectomy, understanding the bifurcation techniques are very critical. And I think we all can agree that left main PCI should be guided 100% of the time with imaging. It's debatable about PAD and hostile ileoformyl disease depending on the discretion of the operator, the utilization of advanced mechanical support devices. I see a lot of patients who present with cardiogenic shock and on the angiogram, sometimes the vessels are deemed too small. And I think that's because they're vasoconstricted or on multiple pressers. But I think that in most patients, if you have, there's a will, there's a way we could get these devices in and oftentimes they could be lifesaving. So that's kind of the presentation. Do you guys have any questions or comments on the use of alternative access in shock or the bifurcation in this case? Amir, you have a nine French now, right? Did you have a trial? Do you think you'd have gone through this hostile anatomy? Yes, I think that the nine French ECP is definitely gonna be transformational. It's a game changer. Barbara is a co-investigator on that. He could share his experience, but yes, to answer your question, it would have easily tracked through not only severe tortuosity like this case, but even PAD. I think now with shockwave for iliofemorals and our experience from the TAVR world, there's gonna be, I think, less and less need for alternative access in the acute setting. The axillary is a really nice access for when you need durability. So you need to keep these devices in for a long time, longer than a few days. But to be very honest with you, in my experience, the best access, if you're gonna use axillaries, is surgical cut down. If you leave these pumps in and the axillary for a long time, when I say a long time, 48 to 72, 96 hours, we start to see thrombosis despite good anticoagulation of the axillary, something that we really don't understand. So if you're gonna keep it in, usually if I have somebody on an axillary in Pelvis setting of acute MI shock, by the third or fourth day, I ask the surgeons to cut down on the other axillary. And put a conduit there for us because we see thrombosis. But in a pinch, I think this is a really good access if you need it for a short duration, obviously TAVR, but Impella to save someone's life in AMI or do a high-risk PCI, the access works really good. Yeah, once you, great case. And once you've made that decision or realize that you're gonna need to drill with less than 2.3 flow in both of the arteries. I mean, I think you're 100% right if you don't feel comfortable going transfemoral and to really take it up a notch with MCS to an alternative. I mean, Impella through an alternative access because a balloon pump would not have been enough once you start drilling and you've got less than 2.3 flow in both of those arteries. I just, I don't think a balloon pump would have been enough. And I think you would have been trying to escalate very quickly in a terrible situation where the cat's already, or whatever, whatever the idiom is, it's already out of the barn. The train's already left the station. Yes. There was a question in the chat. I can't open my chats. Dr. Rab, can you? Was it thrombus or calcium in the LMCA and LAD? Yeah, so it was mixed, but it was predominantly calcium. There was some thrombus in the mid LAD, probably attributing, you know, to the diminished flow that you saw, but the lesions were very, very heavily calcified, predominantly calcium. And I'm not convinced, you know, we do a lot of imaging. I have a hard time making the distinction of thrombus and IVUS, you know, probably maybe some of you guys are better than I am at interpreting it. I find it to be much easier to tell thrombus when we're doing OCT, but on IVUS, it's very hard for me to identify the thrombus. We have a really good image at our lab. He's always pointing it out to me and I still can't see what he's seeing. So I think it's going to take a long time. Amir, can we go back to the IVUS images at some point just for the calcium? And I think it's important for the audience to know that. And while you're pulling that up, I'll also point, I mean, one thing that struck me about both of these cases, you know, these are patients in their 80s, critical disease, MCS, bifurcation. This is what we're all faced with now. These are the normal cases. And I think that's very, very different from 10 years ago. And I think it really coming upon all of us to up our game and keep, you know, incorporating new technology and new skills. And the other thing I thought really was great is there's so much binary decision-making on the fly here that I hope is not missed about looking at data, making decision, pivoting based on what you find. And then also the last thing you pointed out, Amir, which I think is really key, is that you did this case with another colleague. So I don't think that's done enough. And if you have a complex case like this and you have that ability, don't be shy, reach out, particularly early career. I cannot overstate that enough. And I'm glad you made mention of that. And then I'll let you talk about the calcium here. Yeah, well, just one comment because I think that's super important, Alex. I think there's, just so everybody knows, I think there's very few people out in the world that have done as many impellas as Dr. Schreiber. And I would say myself, you know, maybe a handful of people. That being said, every single impella case to this day, him and I do together without question. And if I'm out of town or he's out of town, we have a second operator there who's also in attending and we have the good fortune of working with fellows. But the point is they're very well taken. Every single high-risk PCI case, it adds tremendous. I've never had a case where I regretted having, you know, Dr. Schreiber be my assistant and him vice versa. And I think that's important. You're not gonna need, you know, a co-pilot on every case, but when you do need it, it makes a huge difference. And I think you're very right, Alex, that, you know, at our place, it's a mandate and it works out very well. I know everyone's time is valuable and they're very busy, but I think in these patients, time is well-served. So this image is very important to show to the audience that there's heavy, dense calcium. They can see which protrudes into the vessel, okay? And also over here, between nine and 11, these are nodularities that project. This is a nodular, these are nodular calcified lesions, okay, so there's no question, okay? Now, this irregularity, where we just not have a negative shadow behind it, could be thrombocytin, but these are just nodules sitting in that left leg, okay? Yes. Question about it. But one final question, Barbara, from you, is that revascularization of the non-culprit vessel is a very different thing than the complete trial, okay? The complete trial, most patients were very stable, so you could do them the next day or within a week or within 45 days. So timing of the non-culprit vessel and shock, what are your thoughts about it? I mean, there's a different animal altogether, right? So what are you thinking? And so when they should go to revascularization? Yeah, I have very strong feelings on this topic, and I think it's extremely misunderstood. So the vast majority of patients in culprit shock who survived actually did get staged PCI. And so I think that's something that really is very missing. It's not culprit and then leave them alone. And I think even ECLS shock, which just came out last month, was something that was really interesting to me was that actually 25% of patients had non-culprit PCI, right? And that's from the group that actually did the culprit shock trial. And what it shows is that data is there to help support decision-making, but it is not something that we have to feel that needs to be done on a case-by-case basis, meaning to say that there's a lot of heterogeneity in these sick patients. And so even 25% of ECLS shock patients needed non-culprit PCI. So I think in general, my feeling in the shock world is to try to do just culprit only upfront, don't do anything too complex, and then kind of go case-by-case in terms of what you should do thereafter. I think ultimately most of these patients benefit from close to complete revascularization if you can get that for them, but I think you can definitely stage it, take time with it, and get them started on guideline-directed medical therapy first. Yeah, I think we have a few trials now that says at least it's in a patient where things are relatively stable that it is safe and appropriate to be doing it before discharge rather than waiting longer than after discharge. And so I would lean towards that if, again, such as the cases that you showed. Well, Alex, any final words? I'll leave it up to you as the godfather, but I think we're probably out of time. So you always get the final word, Tanvir. Well, thank you very much. These are really great, but not too common cases. And thank you very much for the excellent presentation. I hope it was educational for our audience. Thank you very much.

mechanical support devices

acute coronary syndrome

left main disease

atherectomy

bifurcation techniques

calcium

laser

orbital

plaque