And thank you to my colleagues who have spoken so far. I think what Dr. Pahuja's show does is phenomenal. And what I'm going to try to do is see if we can put all this together in a simplistic way for a case. My name is Sarasvallabha Josula. I'm an interventional and a critical care cardiologist. I have no disclosures relevant to today's conversation. So the objectives, like I said, was to review a routine case of STEMI with emphasis on routine, discuss my personal approach. Again, like one of the earlier speakers said, there isn't really one right approach. It's what works for you that you can do consistently. And then understand the rationale and sequence of decision making in such cases, oftentimes with a time emergency on your hands. So this was a 69-year-old gentleman with traditional cardiovascular risk factors presented with substantial chest discomfort for 30 minutes. When EMS picked him up, his vital signs were awful, got a liter of fluid. And then by the time he came to the ED, his vital signs were significantly better. On exam, which is a real exam, he had increased work of breathing, a normal cap refill, normal mentation. Oftentimes, this is, again, how to make a complex PCS. Simpler concept is oftentimes when I'm driving in for a STEMI, I have my general cardiology fellow who's in-house go down and do an echocardiogram. The information you get from such a maneuver is extraordinarily important to help you make your decisions. So the EF was about 35%, 40%. There was apical hypokinesis. There was moderate MR. And I don't care about all the things on a full-formal echo. What I really care about is the aortic valve tight, because if I have to do MCS, that's going to fight me. Is the MR really severe, which is going to impact hemodynamics the minute you start giving them a little bit of sedation? How bad is the LV? And without any IV contrast, are we able to appreciate an LV thrombus? All of it significantly changed my decision making. Obviously, if there's a late presenter, you're thinking about an effusion or clot in the pericardium as a complication and other things. But I also try to get as much lab work as I can. Usually, our ED is top notch, and they get these tests right away. So these are his lab work. Lactate is 1.9. He presented early enough that his high-sensitivity troponin was not particularly elevated. This is ECG. Our friendly ED physician circled out the abnormalities for you. But as you can see, there's some anterolateral and some inferior ST elevations, or sorry, anteroceptal and inferior ST elevations with some lateral compensatory changes. And so I take him up. This is his diagnostic angiogram. So I showed you the labs. I showed you the hemodynamics. This is my diagnostic angiogram. This is the other thing I do, again, in the spirit of making things simple, is I almost always get a full angiogram. I resist the temptation to go up with a guide, especially when the culprit is in doubt. And I almost always get an EDP at the very minimum. And if there's any doubt, I'm happy to shoot an LV gram. So this was his diagnostic angiogram. His LV EDP is 30. His systolic was 90. So that gives you, I mean, if his map was, if you assume his map was around 40 or 50, it gives you a coronary perfusion pressure of about 10 or 20. It's an important concept. Coronary perfusion pressure is map minus EDP. So if your map is low and your EDP is high, there is no way you're going to perfuse that coronary, even if you revascularize. So just as a show of hands, there's no official poll. How many think the culprit is the LAD? All right. How many think the culprit is the right coronary? All right. How many didn't want to commit a majority? How many of you would do hemodynamic support? Who would do just vasoactives? Who would do an intra-aortic balloon pump? How many would do an impeller CP? And how many would consider a PCI with a bailout MCS strategy? All right. If you do MCS or vasoactives, which sequence will you follow? I'm not going to do a show of hands. But these are questions that you are often facing when you are taking care of these patients with a time urgency, with an understanding of, oftentimes these cases happen at 2 in the morning and nobody's in their full faculties. So you need to understand, you need to have a template and you need to use the same template over and over and over again. So I always get an echocardiogram. I always get a full diagnostic angiogram. I always dip into the ventricle. If in doubt, I shoot a V-gram. And then I assess where we are. Get as much diagnostic information as you can before you commit to a therapeutic procedure. So I'll tell you what we did. We presumed that the LAD was culprit. We got an impeller CP in for the same reason that he was thrombotic, supposedly in two vessels. He had a circ that was open. We saw late collateralization of the diags, potentially from left to left collaterals. And as you can see, the LAD occlusion was at the level of multiple bifurcation. There were two high-rising diags, a big circ. And these are things that I do to make my case simpler, is that I often go in with a microcatheter, because I don't want to keep falling into the circ and keep wanting to come back when you're trying to open a closed vessel. So I went up with an impeller CP. It took me a while to get the guide up because of his dilated root. But we got single access, which again, as Dr. Pilger pointed out, should be standard of care. Got a microcatheter in. What I did not get would have been a guideliner. But I got a microcatheter in, took a workhorse wire, made it sit in that little nose of the LAD occlusion, and tried a workhorse wire. It promptly crumpled. And then in my algorithm, what I'm doing is I'm going next to often a polymer-jacketed low-gram tip wire, which for me is often fielder XT. And if a fielder XT is not crossing in a STEMI and you're having to pull things like Mongo and other things, you probably are not dealing with a STEMI. It's probably a chronic occlusion. So I tried a fielder. It went into places that I could not recognize. If your wire goes into a place that you do not recognize, do not follow it with a microcatheter. That's the biggest mistake you can make. So I pulled it back, and I flipped to the RCA. I got an AL guide, and lo and behold, it's all between my heparin, my GP2B3A, and my LD unloading. This RCA has revascularized. I love how the slides are getting ahead of me. Sorry. So this RCA, I got an AL guide up from the groin, anticipating a challenging thing. That's the other thing, is the right guide selection. Don't shy away from taking an AL guide if you think that's what you need. Sorry, I can do better on the animation. So as you can see on the second panel, we ballooned. We had flow, we ballooned, but there's a heavy thrombus burden, so I took the penumbra up. That's the other thing, is if you have a highly thrombotic vessel, decide what your algorithm is going to be, because you're going to see things. So the minute I aspirated, he went into Brady arrest. And I said, and our fellow promptly lost our guide, which is all OK. So we got in a temporary transvenous pacemaker from the groin. We were already there. In fact, I may not be recalling this, but I think I had a groin sheet to put in my drugs. So we had a groin sheet. We quickly used that to send up a temporary transvenous pacemaker, got up a fusing rhythm. And then, as you can see, we now switched out to a JR guide, because we'd lost guide access. Switched out to a JR guide, ballooned the vessel, and then did another run with the penumbra. So the initial run was the penumbra. This was actually guideline or aspiration thrombectomy. So when the penumbra is also too small to aspirate your clot, what I've often done is send the guideline down all the way to the level of the clot, and put like a 20 cc on the side arm of the Y connector to get as much clot as you can get back. The crucial thing that you have to do at the end of this is to clean your guide. Clean your guide as well as you can. Bleed it back. Bleed it through the side arm. Pull back into the manifold. Do everything you can to make sure there's no clot in the guide, and that everything is out. So we ended up aspirating. I don't have an IVUS run to show you. We put a long stent, trying to land normal to normal, and then finished the PCI. This is a closing picture. Great flow. And then this is the other thing, is when we talk sequence of events, I did not think it was important to put in a Swann-Ganz catheter at the beginning of the case. But it'd be criminal not to put a Swann-Ganz catheter at the end of the case. So what we did is got neck access. This is the other thing. Even though I had a venous sheet for the temporary transvenous maker, anecdotally, the femoral swans get dislodged far more than neck swans. So if this patient's going to the CCU and is going to be there for a few days with a Swann-Ganz, it's almost always helpful to get a neck swan. So we got a Swann-Ganz in the neck. So in follow-up, two days later, his impella was pulled out. He did great. Got dismissed. I saw him back in the office. Brought him back for a stage PCI of the CERC for a lesion I didn't fully appreciate in the initial angiogram, which he was exquisitely ischemic from, actually, when I was ballooning that lesion. So he did great. Saw him this Monday before I came to the conference. He was doing great. His LAD is still a CTO. We are watching him medically. He's doing OK. He doesn't have clear anginal symptoms. If he ever develops it, we can always go back. But I think my priority now is to uptight rate his heart failure regimen and try to get him to a place where he has passed the ICD cutoff. I think his EF was 30% when he left the hospital. We have a echo coming up in three months. So good recovery during the CICU and hospital stay. Uptighting heart failure therapies, no anginal symptoms. Like I said, repeat echocardiograms pending. So in summary, I think first thing is we've heard this through this talk, but Sky Stage B is bad. B stands for bad. Please do not underestimate the importance of Sky Stage B. It can quickly snowball on you and become just something really terrible. Have a high index of suspicion for adverse events. Have, like Dr. Pauja said, have a plan. Your cerebral aspect of the case is often underappreciated. Have a plan. Plan for hemodynamic embarrassments. Plan for what your PCI strategy is going to be. Have an algorithmic approach to any deterioration, be it clinical, hemodynamic, electrical, obviously coronary. And then I kind of hit upon this. While re-establishing flow is a priority, revascularization does improve outcomes. The hemodynamic status is equally important, or I'm hopeful that future data will show that's probably more important than re-establishing flow. With that, thank you for your time, and I'll be happy to take questions. Thank you.

STEMI management

cardiology

hemodynamic management

personalized strategies

Sarasvallabha Josula