Thanks everybody for having me. I appreciate the opportunity. So this was an 80-year-old patient, had a remote history of TIA a few months prior to his arrival. He came in at three in the morning. He had some right-sided neck pain, woke him up from sleep. He had similar pain off and on for the past two days, but it was more short-lived. His symptoms became more consistent when he woke up. He came in mildly hypotensive, a 96 over 67. However, his heart rate was 74. His x-ray did not reveal anything significant. The emergency department did get the ECG that you see on the right-hand side. Shows maybe a little bit of elevation and leads to three in AVF with ST depressions in V1 through V3. They didn't activate the cath lab right away. They had one of our cardiology fellows review. And in the meantime, they had gotten a CTA of the head and neck, which revealed no dissection and no PE. Patient had a creatinine of 1.28. His GFR was 57. First troponin came back at 77. First lactate was 2.2 and his hemoglobin was normal. And so the patient had ongoing symptoms. The cardiology fellow notified me. This is all within the matter of about 20 minutes or so. And the cath lab was activated thereafter. So we brought the patient to the cath lab. And as you can see, he has some left main disease. Looks like there's some disease in the osteal and distal aspects of the left main. His right coronary artery is occluded. He has his probably culprit lesion within the mid circumflex as well. You can see that it's maybe to me two and a half flow. And then you also notice that he has a pretty heavily calcified prox to mid LAD lesion as well. So this is the scenario and the story that we have here. What would you do for this patient? What's your next best step? Options include immediate PCI. Should we do a right heart cath because he was hypotensive and get a little bit more information? Do we need to think about MCS and if so, a use of a balloon pump or impella? Or should we pick another strategy? Any thoughts from our panelists about what they think is the next best step? My only question would be, was he on any pressers when he came up to the lab at this point? Because he was hypotensive in the ER. Yeah, so he had gotten a little fluid bolus. It didn't actually change his pressure, but he did not require any vasopressors yet. And looking at the RCA, were there any bridging collaterals to convince you that was chronic versus? There were no bridging collaterals, but it definitely had the appearance of a chronic thrombus, excuse me, chronic occlusion without thrombus. One of the things that comes up in the ER frequently is them doing all these CTP and dissection protocols. And the creatinine is 1.2, the patient's elderly. And I've tried to convince our ER for the most part that he really thinks ACS and try to avoid the extra contrast load for these patients. So do you think that was appropriate first step for them when you had the schema with EKG and waterline, well, elevated histroponin to start this? Yeah, no, we've had a very, very similar discussion. In fact, we even talk about, you know, one of the mantras I think in the emergency department is if you think of it, you should rule it out. And so then I always say, you can think of dissection, for example, but I can rule it out for you after I do the coronary angiogram, because, you know, yes, you can have a concomitant RCA dissection and ascending aortic dissection. You don't have to give them their dual antiplatelet therapy in that scenario, but just a phone call to me and then I can always do an aortogram. But, you know, even we can, you know, diagnose PE and all of these other things as needed. But I think with that ECG, I completely agree. I think the cath lab should have been activated immediately and no other testing needed to be done. Yeah, I'll add, even if it's not cath lab activation, but interventional cardiologists consulted. The other thing, which I think will be really interesting to see evolving over time is increased use of point of care ultrasound, you know, bedside echo. You know, I'd be curious to see new ER graduates in a lot of specialties where that's just really part of the skill set. And so I was, when I was looking at this question, I was actually, you know, ask everyone, not just what's the next best step, but what are your thought process? Like, what are you doing? So like, I'm thinking, okay, they're getting the patient on the table. I'm thinking, okay, you know, hypotensive, tachycardic, elevated lactate, hyperperfusion, you know, hopefully I'm, you know, we keep an echo machine in every cath lab. So I'm, you know, just doing a quick bedside echo at the same time. And then I'm thinking my personal first step is to get an end diastolic pressure. So then I have all that data really at the very beginning, you know, leading into coronary angiography too. So I'm just sort of, you know, around the, around the table, so to speak about, you know, not just where it's the next best step, but how are you integrating that information? Yeah, I think in this case, you know, if, if you're fairly convinced that the RCA is not acute, I just couldn't see it very clearly. And you said there were, but that you had the appearance of a CTO, you know, the CERC isn't fully occluded. It's got to me to flow. It's, you know, critical, and it's probably the culprit. But what I mean to say is that when it's a, when it's an acute occlusion, like an LAD, a large RCA, the idea would be that perhaps if you, you know, immediately revascularize, the pressures will start, you know, human dynamics will change pretty quickly. But in this case, there is some forward flow. So I just don't expect crossing the CERC, ballooning it open to suddenly create such a huge change in hemodynamics right away. Which is why in this case, I'd probably opt for, you know, a right hard cap thinking I'm probably going to need an MCS, just given again, that I don't, I don't see things, things look a bit more chronic, that's gotten worse with probably some plaque rupture on top of it in the, in the CERC with the chronic disease in the LAD, chronic disease in the RCA, and things just not necessarily turning around very quickly. So that's, I think I would lean towards, towards that. Yeah, I think that's actually extremely reasonable. I totally agree. I think that the comments that you made, particularly about the the chronicity of the LAD in the right coronary make a lot of sense, right? I mean, at the end of the day, it's not just a quick in and out in terms of getting a fix. And so then, you know, we are talking about the bifurcation, and this was the lesion within the circumflex. And so I guess, you know, what I did is I placed a guide. And as soon as I placed the guide, the patient went into a junctional escape rhythm and became bradycardic. So now, outside of chasing to do a TVP, does it change your plan at all? It's going to change my plan, especially you already have a hypertension, you already know that the patient's hyperperfusing based on the lactic acid and everything else that you've shown. And I would rather be a little bit more proactive versus crashing something on later, get more information. For me, I would have done exactly what Benita said, probably would have done a right heart cath real quick just to get some hemodynamics to know what I need to do. Maybe get the interventional fellow to prep a micropuncture for support, see what I need to do. But definitely going into a bradycardic rhythm, your cardiac output is going to go further down, and you're going to start to spiral. And that pulse pressure worries me, right? It's not just your systolic blood pressure, that pulse pressure itself, even though the systolic is in the 90s, the pulse pressure is very worrisome. Yeah, that's a great point. I'd say I would even go a step further. I think that's way more important, right? Because that's demonstrating in your surrogate ejection fraction that there's not a lot of change in systole and diastole. So this is a good point, I think, particularly for the fellows, all of these little things, it's not just the angiogram, but these little clues even before you take the angiogram that are already starting to, you know, pique your interest and have you thinking about what your strategy might be, even without yet knowing the coronary anatomy. Yeah, so one thing I didn't mention is I did put a diagnostic into the LV when I did the original pictures, and LVEDP was 24. So we have that added piece of information. So I started firstly with a TVP. And then from my standpoint, the patient's not on any pressers yet. I have a very high suspicion, just as you all do as well, that I would need support. And, you know, if I would get myself into trouble, then, you know, that would be my approach. And, you know, I think there's a huge difference between preemptive MCS and bailout MCS. But at the same time, there is a spectrum there, right? And clearly, I'm not talking about using it in just a bailout scenario here. But I felt that because he's not on any pressers, I have a little bit of wiggle room to bring up pressures if I need to, that I could actually, you know, tackle this lesion with PCI first. And so we were a radial approach. And maybe we can just take a second just in terms of PCI and discussing if you were going for PCI here, and you had this angiogram, and you have this lesion. And then after the lesion, you know, it's not necessarily crystal clear how much disease you have. And you have these three almost equal sized branches. What do you do? Do you wire everything at three in the morning? Do you wire the left main and into the LAD and then the CERC and just choose one branch? Do you choose two branches? Always tough decisions, I think, and things that fellows always ask. What makes you decide what to wire? Yeah, so before we go on, in the chat, there's a question on, would you put in MCS and call CP surgery? I personally, I think the EKG showed elevations in the inferior leads and depressions with big R waves in the anterior leads suggesting posterior ST elevations. If they were posterior leads, I'm sure there would have seen elevations. And with ongoing chest pain would have continued down the PCI route. But if anyone else has any questions there to the... No, the treatment is an acute infarct to do private PCI. It's not MCS and CAVG. And this anatomy is really hard. So would one of you want to tackle the modification question and what to wire or not, and then we move along? So I'm certainly putting my main wire in that middle branch, just because it seems like a straighter shot. And potentially putting a second wire down in the lateral branch, the one that is not going off towards the... Yeah, yeah, that one. Only because it looked like in the moving videos that that vessel had less flow. If I remember correctly, it had... That was the vessel that sort of struck out to me with a bit more to me to flow. And then we'll give some nitro and see if things look any better for a distal landing zone. I like it. I didn't give the nitro in this case just because of the hypotension, but I did the same thing. I took the middle branch, thought it was the biggest. Did a quick balloon because I didn't think my ivis would get past it. And then brought my ivis catheter down. And in the back of my mind, I had the idea that this patient's creatinine's one four. He got actually 160 cc's of dye already, 100 for the CTPE. And I don't know why they ran it as two different studies, but his head and neck CT had an additional bolus. So I was really worried about contrast. And here's some still images of the ivis. My ivis imaging, if I play the whole video, becomes very challenging and a huge file. But the top panel here represents what was the baseline in terms of the distal reference. And then as we move forward here, actually the second panel I think is really nice. So remember, imaging can help you just in terms of your bifurcation as well, right? And so just as what Dr. Shah mentioned earlier, you can actually see that that lateral branch actually had disease in it. And so it was pretty clear in terms of the ivis. Here's the large kind of positively remodeled thrombotic area. You can see maybe even a necrotic core. This is clearly not a high definition intravascular imaging. And then there was a lot of diffuse disease within the ostium. There was actually probably, you know, at least 50% disease by ivis, but this was an area that I identified on the bottom right. That was my kind of most healthy segment. And so I went on to balloon and I ballooned both the, after the main branch, I also ballooned the side branch because of that disease. And now I have a little bit of no reflow. So at this point I went back, I re-imaged, make sure I didn't have any dissection. I did not give any intracoronary epinephrine. In my mind, I wanted to basically think about what was next. So blood pressure dropped a little bit, 90 over 60. So I started norepinephrine, five mics, and then I went in to, you know, with my stent. So this was a 3038 drug eluting stent. I stented into the middle blood vessel, landed according to what I thought was, you know, guided by my imaging, both my distal and proximal reference. And so now I'm in this spot here and I take this angiogram after my stent's in. And now this is where I am. Clearly better flow in the middle branch, but not so much in the upper branch. And I'm curious now, does this change your plan at all? I was actually going to ask you one question even before that, Barbara, because this comes up a lot. So about selection of a wire that you use when you're jailing a wire. Because I think a lot of fellows ask that question. In terms of what wires I like to jail or don't jail? Exactly. I find that comes up a lot. People ask, they're worried about trapping, you know, trapping wires, which wires not to use. So what did you do here? So this is a Chion Blue and Menomo. I use Chion Blue Menomo and run through is kind of my three workhorse wires. You know, the run through has a marker on the back of it. The Chion Blue is black and then the Menomo is green. And so it allows me to always identify the three wires that I have. And in this case, I use the two different colors, especially at three in the morning. So, you know, I have zero qualms about trapping, jailing wires personally. You know, there's a nice study in the, that was done that a polymer jacketed wires when they are jailed and then they're pulled back that you can do electron microscopy to cadaver parts and notice that there is polymer within the heart that's actually deposited, you know, that's kind of left over. So clearly, you know, polymer jacketed wires, you may not want to do that if you were worried about it, but is there any clinical consequence of doing that? I don't know. In this case with thrombus and, you know, no reflow, I was very happy that I jailed the wire. You know, sometimes you can't get these vessels back and then clearly you haven't done the patient any good. So I'll be honest. So at this point, I'm like, oh man, now I got to recross. I have a lot of no reflow. I'm on five mics of norepinephrine. He's not doing very good. His blood pressure is still disease, is still low. I have some, you know, left main disease. I had the RCA that was CTO. So, you know, he's not crashing and burning by any means, but I felt I wanted a little bit of extra help. And so I actually got femoral access and put in a support device. Now I didn't choose an impella in this situation, which I know everyone in the world is going to think that I was doing, but actually the most consistently used device in the United States is still an enteroartic balloon pump. And I felt very comfortable that this patient's in stage B shock. His lactate was only 2.2. He's conversing with me. And so I ended up putting in a balloon pump. And so I recrossed. I did a quick piss onto that bifurcation. I did a proximal optimization with a 3-5 balloon. And this was the ultimate result that I got. Much better. And then I, you know, again, it's three in the morning going on to five in the morning. You can probably see the left main disease a little bit more here. And I did want to get a better idea of, you know, he's, you know, kind of borderline. Is there something that I'm missing on the angio? And so I did put the wire into the LAD and just do a short IVUS run. And you can see that there is disease. There's calcification. There's severe calcification in the very stenotic mid LAD segment, but nothing in the left main that I felt I couldn't at least, you know, stop in terms of my procedure today. So that's kind of where I left it at this point. This was the final picture after some vasodilators. You can see the final angiograms here. Yeah, and this is a small point, but especially for if there are any fellows who are on the webinar, but, you know, with the flow that was going on in that side branch, took a third wire or you just pull this wire back. I personally would have taken a third wire at that point, just to keep one wire in place. So I would have potted first and then taken a third wire down before pulling out the jailed wire. Yep, I did. I swapped wires. I didn't pot first, but I swapped wires into the side branch first with a new third wire. I don't also flip flop wires most of the time. I'll just get a new wire myself as well. And then I did regained access to the side branch, kissed, and then did a final pot. Yeah, it saves on contrast too, right? You already know where to go. You don't have to keep popping for it. And then if you don't pot first, sometimes you can, if you, just to keep things moving rather quickly, you can even consider a dual lumen catheter so that you aren't struggling too much getting into, you know, recrossing that whole area. Those are super key points because, right? I mean, the notion, the pot, leaving your wire, going in with another wire, you know, we've all seen these be 15 minute solutions or, you know, one hour solutions. And some of it's just sticking to those algorithms and mentally rehearsing them, you know, ahead of time. And I know there's a lot of great bifurcation apps and resources, and it's probably worth, you know, everyone kind of having those at your fingertips and reviewing them in time of not need so that you have it available in your brain at the time of need. And this was a great example. And I particularly liked the pot point. I try and always remember that too, because it really makes your life a lot easier if you can. So I removed the TVP after revascularization. He went back to his sinus rhythm and I used that access to place a SWAN. So these are his hemodynamics. His right atrial pressure was 15. His wedge increased a little bit. His EDP, as I told you, was 24. His wedge is now 28. Index was 1.93, CPO 0.67, and pulmonary artery pulsatility index 2.5. He's able to be off of the norepinephrine, the five mics that he was on, and he's on a balloon pump alone. So anything else to do? Would anybody want to treat the left main LAD now? Do you upgrade MCS based on these hemodynamics? I mean, you've got plenty of room if you need to add another, or even go back on a little, even EPI if you wanted to choose something else to help with your index and your output. You're right there. You're almost at 0.7 for your CPO. So I probably would have not escalated MCS at this point. I'm definitely not going to go after the left main LAD right now. You've got good flow. You're hemodynamically improving and probably let some of these things cool off, get better perfusion and bring them back. Yeah, and I think that's what culprit shock really taught us, right? I mean, if you can wait, it's probably reasonable to wait. And then there are certain situations where you can't wait. And I think if you can't wait in a situation like this, where I did have to do the left main LAD or anything like that, then I would have probably earlier on have thought to have escalated my support and probably have chosen a more robust support device at that time. But I felt pretty comfortable here not doing that. And I did just that. I stopped, I gave him a little bit of a break and actually he didn't even go to the ICU. There was a bed shortage. He stayed in the cubicles for 12 hours. And so then at 6 p.m. when the nurses wanted to go home, the balloon pump came out. He did great and he actually went to the floor. So I waited a couple of days. So three days later, now we have a little bit more information. So his point of care ultrasound and the ED showed an EF of around 40%, but actually with DFINITY and some time his EF was 27%. As I mentioned, his RCA was a CTO. I, from the LAD, when we did the IVUS, I didn't show that the mid LAD, but it was severely calcified. So I knew I was gonna need atherectomy. He's a recent STEMI. He recently was in stage B shock. So what's your strategy for that part of the PCI? Any kind of quick responses and I'll get right to it. Here's his access if you wanna know what it looks like. And his hemodynamics now are improved or they're still about the same? So his right heart cath was taken out after the procedure. I don't have hemodynamics, but his blood pressure is normal. Meaning it's gone up to like 120? Yes, yes. Yeah. Yeah, so I think it's just sort of depends on if you know this patient or not, right? Meaning depending on which hospital you're working on, sometimes in the city hospital, I don't really know what this patient is gonna do if they're gonna take their adapt, if they're not, and then sometimes I stage it out a little bit. But if you feel like you know this patient, patient's gonna be able to follow up, is gonna be able to take their medications, I then err on the side of fixing before discharge. But I do think- And it may not have come off very well on the images and it may even just kind of gotten lost and forgotten, but his mid-LED was very tight. I mean, it was 90%, very, very tight lesion. I completely agree. I think if you can let him out of the hospitals, reasonable to, but in this case, I didn't think that was an option. So, and whether you use support- If I knew that he's a good candidate for whatever meds and everything, then I would do it in-house for sure. So in this case, I didn't know, should we use support for the stage PCI? Should we not? I mean, I got through everything with the balloon pump. Maybe I could get through it again, except I'm gonna do a lot more atherectomy this time. What is the right answer? So actually, this was version one of PROTECT-4. So balloon pump was not excluded. Don't anybody get me in trouble right now. But it was, I did it by protocol. And so it was an unprotected left main, EF less than 30% after STEMI, need for atherectomy. And so we actually enrolled him into the PROTECT-4 trial. And so I'll be a little bit quicker here. So his right atrial pressure, we're in the right heart cath sub-study was four. His wedge was eight. His index actually came up to 2.2. And then we had to actually do a lot of atherectomy within the LAD. It took six runs, 30 seconds, and he got a very reasonable result from that. So what you see on the top panel is a 3038 drug eluting stent. Then we IVUS into the CERC, IVUS back into the LAD. Our strategy was to use a DK CRUSH here. So we used a four millimeter balloons within both of the vessels. This is the stent followed by the CRUSH in the top right-hand side. Again, I didn't use a lot of dye, so I don't have pictures. This is all kind of IVUS guided. This is the first KISS on the bottom. And then this panel here where my arrow is is the left main to LAD stent, followed by a POT, recross, and then the second KISS. So these are the equipment that we used, ultimately potted with a 5.0. The SKS was done with a 3.5 and 4.5 balloon. And so I think got a pretty reasonable result. Here's the collaterals that you can see to the RCA as well. In this case, the patient was 80 years old, had no symptoms on follow-up. I'm a believer of complete revascularization. I think it's a pretty straightforward CTO to cross as well, but we elected not to do that. So he had early BIRD for a couple of days because he was in that trial. It was removed after two hours, excuse me. He was discharged the following day. He clearly gets follow-up for all of his research studies. So his EF improved 46%, no hospitalizations, no angina. So he's been doing really good. So that was the case.

80-year-old patient

neck pain

TIA

ECG

ST elevation

CTA

PCI