Thank you all for who joined us already. This is my name is Chad Reyes and welcome to the Sky First program. This is our Sky First series that comes to you every three to four months. We started this program first session was four months ago it was virtual the plan is hopefully in the future to have it in person. So Sky First is basically a fellow driven program focused on sharing cases and we're discussing these cases with experts in the interventional cardiology field for techniques or decision making. So this program is a good specifically for interventional as well as general fellows, but also for a practicing cardiologist in all three states Michigan, Ohio and Indiana. I remember when Doug Druckmann started that many, a few years ago back in Boston, but now we are privileged to have it here in Michigan and Ohio and Indiana together. So the title or the focus of this session today is PCI decision in uniquely challenging lesions, calcification, bifurcation, dissection and others. And I would like to thank the fellows who submitted cases. We had a great submission this round, and we really had a tough time deciding which case to be selected. But I'm telling you this, this hour going to be worth it going to be very interesting cases and tough decisions as well. So again, welcome again to Sky and I would like to thank Sky family and also Ivan, Rebecca and the Sky family for inviting us to do this program again at the and Michigan and other three states. Also, thanks to our founding supporters all as well as our co-sponsor Abbott Boston, CSI and Kiasi and Medtronic. I would like to introduce my co-moderator, Dr. Amir Khaki. He is director of mechanical circuitry support and cardiogenic shock at St. John Ascension. He has a lot of experience in high risk and complex. And I'm saying privileged that I trained by him a few years ago, and it's really a privilege to be with him on the same panel. Also, our two faculty, Dr. Daniel Menice is from University of Michigan, as well as Dean Badolas is from Ohio State. Thank you again for joining us. I think it's going to be a phenomenal discussion for the coming one hour. The agenda for today is going to be one hour, as I mentioned, a five hour introduction. We are wrapping up in the second here. We have Dr. Lakshmi Rao, Dr. Fola Serena, as well as Raymond Yao presenting from different places in Michigan from different programs. And again, thank you so much for your submission. And we'll wrap this program at eight o'clock. We'll have discussion five to seven minutes after each case, as well as throughout the case from the moderator, as well as from the faculty. Thank you. Hello, everyone. I'm Fola Karana, Interventional Fellow at Ascension St. John Hospital. I have a very interesting case to present, and I'll be very happy to hear your contributions and suggestions. So I have no disclosures for this presentation. So a patient was a is or was at the time a 59 year old gentleman who presented to the outpatient clinic with chest pain. He had complained of Canadian class three angina, and it was classic angina. And he had an outpatient nuclear stress test that was done that was positive in the infralateral walls. So his past medical history at the time was significant for hypertension, hyperlipidemia and GERD. He didn't have any contributory family history. He denied any significant social history. His labs were pretty much normal. Hemoglobin was 16.5. Platelets were 248. His creatinine was 1.11. His GFR was 95.06. So he came in for a diagnostic coronary angiography, and at the time, we took a shot of the left main, and then we found this huge defect in the proximal left circumflex. At the time, we realized that this was going to be a very challenging case to approach because we deemed this heavy calcification, 99% stenosed. And then further down the left circumflex, we could see this 80% lesion here with mild to moderate diffuse disease in the LED and the RCA. So we decided to plan for a scheduled PCI to the left circumflex. So we took him off the table at the time, and we brought him back. Brought him back. This time around, we went for the femoral approach. We did this because we're going to be going with a seven French guide in order to have options for bailout if we needed it and for additional guide support. We also planned for orbital arthritomy, and we had intravascular lithotripsy on standby. We also had intravascular ultrasound available at the time. So we went femoral, as mentioned, and this was our first picture, which was pretty much identical to the diagnostic picture. We had an EBU 3-5 guide. We were able to cross the lesion with a run-through wire. And we decided to go ahead with orbital arthritomy. Given how tight the lesion was, 99%, we figured that we would need to modify the lesion before going ahead with any additional treatment. So we started with a 1.25 Diamondback CSI, and we went low speed for 15-second runs with 15 seconds of rest in between each run. The plan at the time was not to completely get rid of the entire hunk of calcium, but essentially the plan was to modify the calcium to be able to create a path for further definitive therapy for this patient. So we attempted to IVUS at this time after orbital arthritomy, and the IVUS catheter, as you can see, got stuck in a hunk of what appears to be very heavy calcification. And when we analyzed it frame by frame, we were able to see on this side that there was a huge nodule, even proximal to the point where the IVUS catheter couldn't proceed further. So we decided at this time to do PTCA with balloon angioplasty. So we chose a 2.0x20 balloon. We were able to cross the lesion with it, and we were able to inflate this. After ballooning, we took an angiogram, and we could see that there was some improvement in the lumen, but definitely we're still a far way off from opening up the lesion. So we went in with a larger balloon, a 3.0x20 millimeter compliant balloon. And then we did an angiogram afterward, which showed also slight improvement, but weren't there yet either. So we attempted IVUS again at this point, and the IVUS catheter, unfortunately, couldn't cross at this time either. So we decided to go on with intravascular lithotripsy. So we used a shockwave 3.5x12 millimeter balloon. We were able to cross the lesion successfully. We did five runs, essentially 10 pulses each treatment run at the spot where the calcification was. It was pretty easy to identify that. So this was the shockwave balloon. And then this was the angiogram that we did right after shockwave. So we could see that for everything we had done so far, we're able to gain some significant ground using the hybrid approach of both CSI and intravascular lithotripsy. So at this time, we did try the IVUS run and were able to have a successful run of IVUS. So I'll just let it play. We could see at this time that the patient essentially had 360 degrees of calcium for the most part. And we could see that we had cracked the calcium with our intravascular lithotripsy. So we felt like the lesion was adequately modified at this time with both of the modalities that we had used. So at this time, we went ahead and we deployed our stent. So it was a 4 by 23 millimeter drug-eluting stent. We inflated it at 16 atmospheres for 30 seconds. So here's that. We had good expansion. And then while the balloon was up, we took an angiogram just to make sure that we hadn't compromised the LED and we had good flow. So we were happy with our positioning. After deploying the stent, we did another angiogram and we were very pleased with the results. So at this time, we went ahead to IVUS the lesion again. And minimal stent area was 7.2 millimeters squared, which was a good result. Much better than we had anticipated. So then at this point, I'll quickly just mention that since we had made good progress with the proximal left circumflex, we then tensioned to the mid-circle lesion that we had mentioned earlier. And we essentially went ahead to IVUS that. Then we went to balloon that with a 2 by 20 millimeter compliant balloon. We did three inflations there for 15, 8 and 10 seconds. And we essentially scaled up to a 2 by 5 by 40 millimeter balloon and did another run of angioplasty there. So after angioplasty, this was the mid-circle lesion. And then we went and deployed a 2 by 5 by 38 millimeter drug alleging stent at 8 atmospheres for 28 seconds. With good expansion. And this was our angiogram. No, OK. We then optimized the stent with a non-compliant balloon, 2 by 5 by 20 millimeters at 12 atmospheres for 10 seconds. And this was our final angiogram. So this was the proximal. This was the mid-circle lesion. And needless to say, we're very pleased with the results. So essentially, in summary, I feel like this case highlights that even though Sibelius calcified lesions have been historically a very great challenge to interventionalists to treat, using this synergy between various modalities such as the hybrid orbital arthritomy and intravascular lithotripsy that we use essentially gave us excellent results. And I'd also like to mention that we are committed to imaging before definitive therapy. So we weren't deterred by the fact that we had been unable to advance our IVUS twice. We went ahead and essentially still got the IVUS images before we decided on the length and sizing of our stents. So that's my case in summary. Thank you. Thank you. That was a great case. I was actually in that case and followed the entire case. And I think some of the important things that she highlighted are worth discussing. One of them is you don't have to be committed to one debulking device. And I think there's tremendous value from combining arthritomy such as rotational or orbital or even laser with IVL. You can make the case, you know, that it's expensive. But I can tell you that without orbital arthritomy, I submit to you that without IVL, we would not have had adequate prep to deliver our stent. And I think, again, to highlight Phyllis' point, which I think is critically important, is the utilization of imaging and the commitment to that. We at St. John's use imaging about over 90% of our PCIs. And we're committed for pre-imaging, pre-PCI. So you could see we chose a 4-0 stent and post-PCI to make sure that we have good expansion, which you saw there, really good apposition and no edge dissection. So there's a lot to learn from this case for the fellows as you guys graduate. We'll be taking on very hard lesions like this. But I think with the tools that we have, you could do it safely and likely give these patients a very durable result. And in my opinion, I'd be interested to hear what my colleagues think, but a really good PCI like this one, particularly into the CERC, I think is going to be a much more durable option than, for example, a vein graft to the CERC or a stent without imaging or adequate prep to the CERC. So those are the teaching points that I think Phola did a wonderful job in. From a technical perspective, this is a very hard case. Again, I want to commend Phola, who is extremely talented, for doing this case so early in her career. So congratulations, Phola. Thank you, Dr. Kekin. Dean or Danielle, do you have any comments about the imaging or approach to this lesion? Yeah, first of all, congratulations. That's a great result. And it was very smart how you guys combined different tools, which I think is going to be extremely helpful. The first thing, just to point out, when you start out the case, I agree with you. If it's anything complex and you need support, I know we all train our fellows now on radial first, but I'll go femoral, 7-8 French with a destination sheath, 45, 50 centimeters, to just increase your chances. You're going to just, it's going to make your life a lot easier. And I'm not saying you can't do this necessarily, not this case, you can't do some of the higher risk cases radial, but I do think it's something that I lean towards, too. And I would have done the same thing. I'll tell you, I like the combination, and it definitely is helpful when there's that much calcium. What I typically find, though, is with the shock wave, the biggest issue, and I'm sure colleagues and the fellows who have experienced this, is deliverability. There's no way you would have crossed that lesion with that shock wave. And to be honest with you, for us, it's because of the nature of where finances are going with hospitals, there are eyes on us with the use of these devices. And to the point where, well, before we even open it up and we're thinking shock wave, we'll get a 2.0 or a 2.5 balloon to make sure it crosses, because it's a big chunk of change. I feel like I've had more issues with the shock wave crossing. And when I use rotation orthorectomy, I typically find that I can do the case with that and then with a non-compliant balloon, but not vice versa with the shock wave. But I definitely like that combination. It's smart. Just something to be mindful about is that every time you open it up, it's right now it's a little bit on the pricier side. But I like the combo. Did one the other day, combined the two. It actually works well. But I do feel like a rotoblader, I feel like you can get away sometimes with just using that and be done with it, depending on the lesion. Yeah, I'll jump in, too. I think some of your comments are right on. I think we've all got to be comfortable with a lot of these devices and be able to feel comfortable interchanging. I actually thought this was interesting, because this is one of our biggest, I think, frustrations, these nodular calciums, right? This was not, I mean, it was just such a big rock in the chunk. And they always make you nervous, because you kind of feel like the calcium's got to go somewhere. And you kind of wonder how hard to push and how much to go with it. And I think for me, when I see that, rather than kind of that diffuse calcium, I probably would have, my own personal practice might have been to try to debulk a little more with rotational arthrorectomy. But you show that you can do just as well with orbital, as far as getting what you do. I'm kind of curious. I actually thought, you know, after your orbital arthrorectomy, you actually, your balloons were expanding well. And so did you think that, what did you think the shockwave helped you with more so than when you attempted to stent without lithotripsy? I mean, it's hard to disagree with what you got. The result was fantastic. So I'm just kind of curious. But if you look, your balloons all expanded. So, you know, you always kind of wonder, you know, you don't get a second chance once the stent goes in. So I was kind of curious what you were thinking. Yeah, so me and Fola had that conversation, Dan. Before I answer that, there's a couple of things I want to, you know, piggyback on what you and Dean mentioned. One is the deliverability of shockwave is the problem. And the fact that the length of the shockwave is a problem. So it's a first generation device. I think as we get the next generation, it's going to be more deliverable and we'll hopefully have longer ones. One of the tricks that we use is use a guideliner a lot. If we can't go and we deliver the guideliner and unsheathe the lithotripsy balloon, that's a good tip and trick for the fellows. As it relates to your question, Dan, which I think is very reasonable, is if you notice, we were committed to imaging. And I think what happens, unfortunately, not infrequently, is this what I call stent regret, where you deploy a stent in an inadequately prepared lesion. And at that point, it becomes much, much harder for you to take care of. And if you looked at our multiple IVUS runs, IVUS probably doesn't have the resolution that you appreciate with ACT, with OCT. But we wanted to show that we had fractured the calcium and we wanted to show, which we were able to demonstrate, and you bring up a good point, Dan, full expansion of a non-compliant balloon. But if you keep in mind, this vessel was 4.0 on IVUS. We got a 3.0 balloon fully expanded. We didn't see adequate fracture until we did the lithotripsy. And so you could be critical and say, hey, you guys are spending a lot of money and you're doing a lot of things, maybe not necessary. But I would subject to everyone on the call is that it's worth it spending extra money and extra time to get a higher quality result and helps in anticipation that it's going to be a more durable result. And that's how I would justify the utilization of IVL in this case and all the modalities that we used. It was definitely an expensive case. But that being said, we hope it's going to be a worthwhile, durable case. If the patient comes back, then you lose out from an economic perspective. As far as safety is concerned, Dan, I was very concerned when I saw the lesion. And so we took the patient off the table. As a matter of fact, this patient happens to have a lot of resources. And I encouraged him to get other opinions. He actually went to Cleveland Clinic and went actually, believe it or not, to Texas Heart and got two opinions and ultimately came back to us because of I quoted him a two percent mortality risk because I was I like you, Dan, was worried. Where is that calcium going to go? These aren't like calcific lesions that we see every day that are circumferential. This was a huge intravascular nodule. And I was I was concerned. And so we were thoughtful enough to take the patient off the table. I encourage all my patients to go get second opinions, particularly if they're high risk, and I never want to talk them into things. Actually, I send a lot of them your way, Dan, to the ivory tower of medicine. And about half the time they come back and half the time you guys take care of them. But I think it's a good idea to take high risk patients and get other opinions for the patient's sake. I think that's a great point. I mean, we teach our fellows a lot, you know, about, you know, stopping, pausing, having that conversation, particularly earlier in your career. But I think what you'll find is exactly what you said, Amir, that a lot of times patients will appreciate it and they'll come back, you know. And if you tell them, you know, what you thought and you understand, you know, that, you know, being concerned and understanding that it's high risk doesn't mean it's not worth doing. And I think most people will appreciate that. And I have a lot of folks and, you know, it may be up in the ivory tower, but a lot of folks like to go to Cleveland from here and get other opinions. And a lot of times they come back. They appreciate what you did. Because a lot of times they're going to hear the same thing elsewhere, you know, and they appreciate that. So I just want to ask you and Dean as faculty and Shadi, do you guys, what is your commitment to intravascular imaging pre and post? Would you say you do it, you know, occasionally, you know, 20, 30% of the time? Do you do it half the time? Are you fully committed to doing it every time? The reason I ask is I really think that it makes a big difference. Anecdotally, we do have some data and we have some randomized trials going on now that potentially could change the way we do things. But what do you guys do institutionally? What is your commitment to imaging? I would say institution-wise we are in the 13%. Personally, I am more closer to 70, 80%. That's it. How about you? Yeah, we do quite a bit of imaging, but I will say, I'll just, I won't talk about it in a group, but at least for myself, I will say that it depends on what I'm going to fix. I mean, if it's a 2-5 vessel or, you know, and it's a short 10 millimeters, I'm not going to, I'll be honest, I will not use that. But when it gets more complex, proximal, I think the biggest thing for the fellows is size. It's deceiving. You always think it's a certain size. It's always bigger than what it is. I tend to image quite a bit and I actually do both. I think pre-planning is actually helpful, not just post. So Dean, I would challenge you, Dean, on the 2-5. How do you know it's 2-5? I mean, that's a problem. And I'll tell you from my own experience, I really, I fancy myself a very talented operator. And when I went to St. John, I was not doing intravascular imaging on every case. And I'd been practicing probably for about 10 years. My practice has totally changed after imaging. And what I realized in retrospect is that I was undersizing most of my PCIs, you know? Well, as you start to image, you'll start to realize that these vessels are actually much bigger and can tolerate much bigger than we could angiographically appreciate. So, and- That's a good point. I would actually, I was oversizing and that's based on personal experience. I mean, when we started, we, I was, it was nonstop. And after doing, you know, several, several hundred PCIs, you get to realize what you feel comfortable, what your eyes feel comfortable with. And I would say certain, it didn't change my practice on certain types of lesions in certain vessels. So I think it's just, I don't think it was necessary. But again, I think it depends on the case. I think it depends on your experience, your comfort level. And I think there's a difference between if you're getting a 4-0 Prox LED or it's like yours calcified to see what we're saying calcification is to see if you need to modify the lesion. I think that's extremely important, but I think it's also based on your own experience. I mean, remember everybody in this, on this call is going to build their own experience through time and not every, you know, not every study is going to be exactly like what you're saying with the two fives. I mean, maybe you undersized. I used to oversize way too much. And I think that's what I learned to adjust. So, you know, I think everyone in practice is going to find their own, their own, their own algorithm. You don't want to do it. Sounds great. So just for the sake of time, I would like to ask Dr. Rao, it looks like she's ready to share her screen. Can you please unmute yourself Dr. Rao and share your screen? Yes. It's a great discussion. I don't want to, I hate to interrupt it, but we have one, 30 minutes and we have two more cases to go through. Perfect. Are we good? Yeah, perfect. I can hear you good. Thank you. Sorry everyone for the delay. So my name is Lakshmi Rao. I'm a first year cardiology fellow at McLaren Macomb Oakland. I'll be presenting approach to revascularization and an inferior posterior myocardial infarction. Shocked the rock in the setting of impella supported cardiogenic shock. I have no disclosures. So a little bit about our case. We had a 92 year old female who presented to our hospital via EMS with complaints of chest tightness, diaphoresis and dizziness. She initially reported symptoms began three days prior with initial resolution. However, she did have recurrence of her symptoms on the day of admission, which prompted her to call EMS and take her to the hospital for further evaluation. As you can see her past cardiac history is listed there. She had a history of a cabbage, a three vessel cabbage at an outside hospital that we did not have records for in 2010. Hypertension with hypertensive heart disease, hyperlipidemia, statin intolerance, bradycardia, moderate AR, mild MR. And then you can see her past surgical history, remarkable social and family history and her home medications currently listed there. This is the EKG that we got paged about and the cath lab was activated for. So EMS sent this EKG over, there was concerns for an inferior posterior STEMI. So the blood pressure in the field was 85 over 58 and that was post one liter of fluid resuscitation. As you can see her heart rate, she was bradycardic and she was maintaining her O2 sats on room air. We were waiting for her when they brought her in by EMS and we initially evaluated her. The patient at that time didn't have any acute complaints. Her symptoms did resolve by the time we saw her in the ED. However, we noticed that she was having increasing oxygen requirements. She went from room air to two liters of slow up titration. By the time we rolled her out, she had mild conversational dyspnea. On the monitor, she still continued to be sinus brady, but she was normal tensive. Her systolic was in the 120s when we were examining her. However, during the exam, she did have recurrence of her chest tightness and given her EKG with the dynamic ischemic changes we saw, we discussed with the patient, the risk benefits of proceeding with possible intervention and taking her to the cath lab, given the fact that she was 92 years old. We assessed really quickly her functional status along with her baseline exercise tolerance. Believe it or not, this 92 year old was biking one to two miles a day during the summertime and had a stationary bike at home and was tolerating that up until recently. So we took her emergently to our cath lab. And as you can see, we performed the initial diagnostic cath. So we performed ultrasound, guided right common femoral arterial access using a micropuncture technique. We used a five French shale forward diagnostic catheter to shoot our selective left coronary images. You could see that there was mild osteotapering causing a 10% stenosis in the left main, proximal subtotal occlusion of the LAD. The left CERC was a large caliber vessel, but there was 99% subtotal occlusion that was located ostally that we were concerned about with TIMI2 flow in the remainder of the vessel. In regards to the right coronary angiography, we attempted to find the native right along with the suspected grafts to the right. We used multiple catheters. We used a JR4, an RCB, an AL1, an AR1, an AR2, and a B2, but unfortunately we were unsuccessful in finding the native right or the SVG to the RCA graft. So we proceeded to go with a left heart cath at that time using an angle pig. We performed our left heart cath. We noticed the LVEDP was 26. We did perform a supravalvular aortography, which did not give us any evidence of a vein graft to the RCA nor visualization of the RCA itself. So then we shot the SVG to diag angiography, and we used a JR4 diagnostic catheter at that time that showed a patent SVG to diag graft. It was small and diffusely diseased. It supplied a very small territory and was essentially functionally occluded. So after attaining and reviewing our diagnostic images, it was felt at that time that the culprit lesion was the subtotal occlusion in the left osteoleft cerc, sorry, the osteoleft cerc. Given we were unable to visualize the native right coronary artery nor the prior bypass graft there, we decided to proceed in treating the circumflex first, and then later on, if we can, attempt to look further for the RCA and prior bypass graft. Unfortunately, at that time, we saw that her blood pressure started to drop. Like we had said before, we rolled her back. Her systolic pressures were in the 120s. Her MAPS were 65 and above consistently, but we noticed her blood pressure was starting to trickle down. And she was hypotensive, systolic in the 50s with her bradycardia still with rates in the 50s. So we started a dopamine drip with plans prior to even initiating any sort of revascularization to place an Impella CP, which is why we performed a right femoral angiography really quickly. During that time, unfortunately though, the patient did develop a V-fib arrest. She was defibrillated at 120 joules with successful restoration of her initial sinus bradycardia. Until we could quickly place the Impella CP successfully, we initiated a levophed drip shortly, like a short duration until the Impella CP was placed. So we placed our Impella CP and quickly shot our left subclavian angiography to look at the LEMA to LAD. So as you can see, our selective left subclavian angiography was performed. It was widely patent. And then going through our predilation attempts. So initially the lesion was predilated with a 2.5 by 12 millimeter compliant balloon. We attempted to advance a 3.0 by 20 followed by a 2.5 by 20 non-compliant balloon. Unfortunately, the balloon wasn't able to pass or advance. And then following that, we were able to track a 2.5 by eight millimeter non-compliant balloon across the osteocircumflex lesion and perform multiple inflations in the proximal left osteocircumflex and distal left main. So then we serially predilated with 3.0 by 12 millimeter non-compliant balloon and then attempted to advance then this 3.5 by 15 millimeter non-compliant balloon, which would not pass. So at that time, the lesion still was very rigid in the osteoleft circ. So we decided to proceed with a plaque modification strategy utilizing shockwave intravascular lithotripsy. So at that point, like I said, we decided to proceed with a shockwave. So we threw down a ProWater wire into the distal circ, threw a 1.2 by 12 millimeter over the wire balloon. This was exchanged then for a long Grand Slam wire. We then performed shockwave with a 3.0 by 12 millimeter balloon. In total, eight treatments were performed in the proximal osteoleft circ and left main. After that, we were able to dilate further with a 3.5 by 20 millimeter non-compliant trach balloon and then perform additional predilation. So then now, after we were able to modify our plaque, we advanced a 3.5 by 28 millimeter Zion SkyPoint drug-eluting stent. This was deployed in the proximal circumflex and that was extending back into the left main. The stent was initially post-dilated with a 4.0 by 20 millimeter non-compliant balloon. And then we performed IVUS using an OptiCross catheter. It demonstrated the proximal reference vessel diameter of approximately 4.5 millimeters. The mid-stent appeared well opposed. However, we were unable to track the IVUS catheter to visualize the distal stent. Because of the patient's age, which again, she was 92 years old, and at that time, the procedure length, because I believe that by the time we got the IVUS down, we were around two and a half, three hours in, we decided to focus on the proximal and mid-stent. So then the proximal and mid-stent was post-dilated with a 4.5 by 20 millimeter non-compliant balloon. Following this, when we pulled out our 4.5 by 20 millimeter balloon, unfortunately we lost our wire or wire access at that time. So we recannulated the left main, which is recannulating on this side with a sixth French EBU 3.5 guide catheter to perform our final angiography. At that point, the vessel was widely patent. We didn't appreciate any residual stenosis and there was TIMI 3 flow. After we revascularized our CERC, we saw that the CERC was the dominant vessel and given the improvement in ST segment changes on our EKG, along with resolution of the patient's chest tightness, we elected to conclude the procedure at that time. So after we revascularized the patient's circumflex, the impella CP was able to be weaned off by the end of the procedure. And we elected to remove the impella at that time. Two perclosed sutures were deployed using a post-close technique and with an aid of an eight French short sheath. The impella sheath was removed, our perclosed sutures were deployed, excellent hemostasis was attained. Prior to transfer then to the ICU, we even got the dopamine and levophed drips off. The patient's systolic blood pressure was in the 120s. Her MAPS were significantly above 65 even after the drips were discontinued and the impella CP support was removed and we successfully transferred her to the ICU. We initiated our guideline-directed medical therapy, assessed the patient in the morning and she was transferred out of the ICU later that day. So this was just mapping out some of our decision-making process when I was talking with my attending during our STEMI here. Essentially, we talked through that in the whole case that she was an elderly patient but given her great baseline functional capacity and exercise tolerance, and she was willing to take on the risks and the benefits associated with proceeding, we underwent the procedure. We did talk about possibly using a balloon pump initially, but we elected to go with true support, or not true support, but impella CP support to assist with our revascularization. We went through all of our strategies for revascularization along with our plaque modification choice that we decided along with post-stent deployment imaging. And then lastly was our, I guess, decision on how we would close our access site, which we used a per-close, post-close technique at that point. Some discussion points here was the idea of early placement of mechanical support with impella CP, even in pre-shock or cardiogenic shock, Sky Stage B. And overall talking about the impella removal, we were discussing that whether it should be post-procedure, but because she was doing so good, we knew her down and off support, we decided to remove it instead of delaying removing the impella. And then the idea of pre-closing versus post-close, which it was a tending preference to go with a post-close technique and in the setting of a STEMI to not delay setting up a pre-close technique at that time. And that's it. Thank you, Hara for a great case. We have five minutes for discussion. This is open for the panel to talk and to have question and discussion. And also please use the chat box for the audience too, if you have any question or comments. So Dr. Rao, first of all, congratulations. It was a great case. A couple of things that I would like to point out that I would have done differently, but again, you had your patient survived, so I can't be too critical, but for all the fellows, I feel very strongly about the utilization of hemodynamics. This patient I noticed did not have a right heart cath prior to placing the impella, number one. Number two, let's say if you sit here and you say, well, Dr. Khaki, he was too sick. That's unreasonable. I'll accept that. But you did a very complicated PCI on a patient who was on multiple pressers, who required, you felt was sick enough to require a mechanical circulatory port. And what I don't understand is I think it's better to be lucky than good, is the justification to remove the impella without a hemodynamic evaluation, particularly with the patient who's still on basal pressers. So in this particular case, you got lucky, but I could tell you that a lot of patients aren't that lucky and have hemodynamic collapse either shortly after removal of the impella or in the intensive care unit. So from a teaching perspective, I feel very strongly if you're gonna use any device, be it balloon pump, be it impella, be it ECMO, be it acapella, whatever type of support device, it should be guided by the hemodynamics. And I'll tell you guys, the blood pressure, systolic blood pressure is not enough. So this notion of normal tense of shock is real. So you could have a blood pressure of 110 and have a cardiac output or index of 1.2, 1.3. That patient's a lot sicker than the blood pressure may lead you to believe. So my advice to you guys, if you're gonna use mechanical support devices, please do it with right heart cath guidance and weaning patients, particularly who are in shock, maybe not so much in high-risk PCI, should be guided by those hemodynamics. If you don't wanna do a right heart cath, then you don't believe me and say there's not a lot of data. So fine, a basic test that you could do is a mixed venous O2 and if this patient had a mixed venous O2 that was 30, you're in a lot of trouble taking the impella out. If that same patient has a mixed venous O2, for example, 55 or 60, then the likelihood of a successful wean goes up significantly. So that's kind of my advice, but again, congratulate you and your team. I've done a lot of impellas and I could tell you that I don't have many patients who are nonagenarians that have survived the cardiogenic shock, regardless of what I do. So you did something right and should be congratulated. Thank you. Yeah, congrats on that case. That's like guns blazing. What did it look like after you ballooned it? I think you had that figure from left to right and I think you ended up before the lithotripsy, I think it was like a non-compliant. What did that look like? So Do you remember, do you have TIMI 3 flow at that point or just in calcium or still? I don't want to comment and say yes, if I'm not 100% certain, but I can find out and let you know. Oh, I'm just curious. Because at some point, if you restart flow, you can just, she's 92 and you got TIMI 3 flow, you don't need to necessarily keep pushing it. A lot of times these patients, I mean, they're still going to, they're going to have flow a day or two, three later with the dust settle. And, but man, that's, it's easier, it's easier said than done. Trust me when you're there, it's a different story. You're in the thick of it. And I agree. I think hemodynamics is key for impellus, but I would not, I would have not done it before putting impella in it and you're trying to save her life. You just, you guys did what you needed to do. But I think maybe I was referring to the, after the fact, I think it's extremely important. They should go hand in hand, but, but boy, congrats. That's a, that's a tough case. Thank you. Great case, Dr. Yao, do you want to share your screen? Again, for the audience, if you have any questions or comments, please raise your hand or use the chat box. All right. Just for the sake of time, maybe we can leave five minutes at the end for any questions for Dr. Yao. Thanks again, Dr. Yao, for your excellent presentation and case. Can everybody see my screen? Yes. All right. Wonderful. My name is Raymond Yao. I'm one of the third year general cardiology fellows at the University of Michigan. And I'm happy to be here today to present to you my case. I have no disclosures or conflicts of interest. The patient that I'm going to be presenting today is a 67 year old man who was admitted after a right lower extremity wound IND. After his admission, he was noted to have an episode of dyspnea and ultimately was diagnosed with an end STEMI. But I'll give you a little bit of a brief overview of his clinical course before he met us. Back in April, he had a bike accident and an unfortunate right lower extremity injury that resulted in a lot of right lower extremity procedures, including washouts, need for external fixation and antibiotic beads. Unfortunately, during this hospitalization, he suffered an end STEMI at this hospital and they performed a left heart cath with coronary angiography, which demonstrated an osteoleft main 70% stenosis and a trifurcating lesion of 70 to 80% stenosis involving LAD, a ramus branch and the left circumflex. At that time, a CABG was recommended. Unfortunately, this was deferred until September of 2022 due to concern for a chronic right lower extremity wound infection. Unfortunately, when September rolled around, the CABG was deferred due to concern for abscess in his leg. And so he went for subsequent orthopedic washout and CABG was again deferred. He then presents to us, or this is his outside hospital films that I'll just show very briefly of what the lesion looked like. As you can see here, he has a trifurcating lesion that involves what appears to be a left circumflex, the LAD, and a significant ramus branch. He ultimately presents to our hospital for a debridement of his right lower extremity in mid-October. After his IND procedure, he has an episode of Dyspnea on exertion while in his room and a troponin was drawn. He was also complaining about a little bit of chest pain and he was diagnosed with an endostomy. He also had a couple episodes of flash pulmonary edema over the next couple of days and ultimately cardiology was consulted. And we did come to find that he had this main trifurcation lesion that was known. And so we ended up obtaining the films and having a heart team discussion. And through our heart team discussion, as you all know, heart team discussion is a class one recommendation for any patients who optimal treatment strategy is unclear. And so through our heart team discussion, we calculated an STS score and also a syntax score. He was quoted a risk of mortality with surgery of 0.7%, renal failure of 0.6, and his morbidity and mortality of around 5%. His syntax score was calculated to a total of 31. Unfortunately, through our heart team discussion, there was concern that he would have a chronic right lower extremity infection and due to his mobility issues would have inadequate rehabilitation post-CABG. And ultimately the decision was to proceed with a percutaneous coronary intervention. So we ultimately went with an eight French, which shot some diagnostic shots first. And here's our repeat coronary angiogram. And the decision was ultimately made to proceed with a PCI. So we upsized our access from initially six French to eight French. And we had chosen left fem because we wanted to avoid the right groin due to his right lower extremity injury. And unfortunately his radial arteries were quite small. So that did not allow us to provide access there. I was going to kind of turn to our panelists for now and just get some initial thoughts on our coronary angiogram, what they would do with this lesion being that it involves the LAD and the circumflex coming from the left main. And are there any particular concerns about this ramus branch? You know, one thing that I would do is I'd go back to the surgeons and I would push, I would push for a off pump Lima LAD lateral thoracotomy. If they don't want to put the patient on pump, cross-clamp the aorta, they don't want to do any of that stuff. Then I would push for that and do a hybrid and then go back and potentially stand because it's trepidation lesions. I mean, as you know, they're challenging. That's why you're showing this case, but, and it's, you know, we've done quite a bit of hybrids and we published in the space and I think it's something that has mitigate some of the risks of surgery. It's something to think about. But I get it. Each surgeon's panel, there may be surgeons on the call, you know, they'll, they'll stick with their guns and they'll say, no, no, no. But we just, you know, we, we go back and we push and sometimes this is what we get. Sometimes with these trepidation lesions, we'll, we'll push for a pump Lima and then we'll go and kind of clean up the rest, but these are challenging. Definitely. And yeah, there was a lot of conversation with kind of the orthopedic surgery team because they were kind of eager to obviously wash out his right lower extremity, which at that time had an abscess and put in a spacer and about more antibiotic beads and proceed with that surgery. But given his coronary anatomy, they were hesitant. So there was some urgency as well to, to getting some revascularization here. The other thing, Dean, I'll tell you, I was, I was part of the heart team as one of the extra seven consults. And, and, you know, the other thing is, you know, first of all, this happened, he was in a bike accident in Connecticut. And while we had actually was a still frame photo from an iPhone, that was the only kind of image that we had when we had initially seen him after his pulmonary edema. He also had not walked in about six months. So our surgeons were really, it wasn't just infection. He's been basically laid up. He had a bad, he had an open fracture with a degloving. He, you know, he was an otherwise fit. This guy was biking up until that point, but six months he'd been essentially bed bound. So there was some real concern about his ability to rehab. And, you know, and so I think that according to what, along with that, and what Ray was saying, you know, that really there was a lot more that needed to be done to try to clear this infection. You know, we thought, you know, with our surgeons that, you know, we, you know, yeah, it's going to be a challenge. It actually came up, you know, we kind of pushed another call. We don't think we didn't think you guys could handle a trifurcation or, you know, we can, we think we can get them stabilized, get them through this. And, you know, if we have problems on the road, you know, surgery would still be an open option Yeah, sounds great. No, I agree with Dan. I think we often underestimate, you know, a patient's ability to rehab the risk for cardiac surgery. And this patient, at least in the institutions in Detroit would have been surgically ineligible just by virtue of the fact that he couldn't be rehabilitated for, you know, post-surgery. So I think it's very reasonable. Most people, most surgeons don't want to take these patients because they do poorly. Very much. And thank you for providing that context, Dr. Moniz. For sake of time, I'll push forward and we can continue with other discussion. Obviously, I have a question about bifurcation strategy. So for our strategy, we ended up when we started the procedure and shot our repeat coronary angiogram, our decision was initially to perform a decay crush of the involving the LED and the left circumflex with the circumflex as a side branch. So we did perform IBIS imaging here. I did not show that here for, from a sizing standpoint, but we ended up doing angioplasty of the circumflex, the LED followed by the circumflex with 3.0 by 15 millimeter Euphora RX balloons. And then ultimately we stented the side branch with a 4.0 by 18 resolute frontier stent from the left main in the circumflex. Simultaneously, we had a 3.5 by 15 millimeter NC Trek jailed behind that stent in the left main into the osteo LED in preparation for performing a decay crush. And so I was going to have another discussion slide, but at this moment we took a pause. And when we looked at our repeat angiogram, which was on the previous slide, there was concern for a potential inability to rewire or rescue the ramus branch. At this point, the ramus branch wire had been pulled. And, you know, we looked at the sizing of the left main to the circumflex and with one of one vessel size from the left main in the circumflex, we wondered whether or not doing a decay crush of that stent would be the right move. And so we started considering other strategies. And the one that we favored ended up being a culotte strategy. So, you know, for sake of time, I'll continue to move forward, but we ended up rewiring the LED through the left circumflex stent and performing IVIS over this wire to make sure that the wire that we used to rewire the LED was within the stent, at least within the left main portion. Because at this time we hadn't potted the left main portion of the stent. So rewiring it, you could potentially get under the stent strut. So we wanted to make sure we were within that stent before performing a culotte. As you can see from our IVIS, our wire is indeed within the stent. So we then proceeded to perform a strut dilatation and main branch stenting. We dilated the stent strut with a 3-5x15 NC trek, and then subsequently stented from left main into the LED using a 4-0x15 resolute frontier stent. We then performed a proximal optimization of the left main segment using a 5-0x8 NC emerge, and then performed kissing balloon inflations using a 3-5x15 and a 3-5x20 NC emerge in the LED and left circumflex respectively. And then performed a final pot with, again, that 5-0x8 NC emerge. And here's our final result. That's awesome. And ultimately, our patient was loaded with Plavix. And given, again, orthopedics' urgency of wanting to have a washout of his leg again and to put in an antibiotic spacer, they took him next day for his procedure. He actually was discharged from the hospital He actually was discharged five days after this procedure and followed up in clinic a week after, and is doing really well. He's following up with ID, and they have a good plan going forward for his right lower extremity wound. So any final thoughts from the panel and the faculty here would you have chosen a similar strategy using a DK crush up front and then maybe even sticking with a DK crush or converting to a coulant? And would you do anything about that ramus branch, ramus high OM branch that was left? Because there is still TIMI 3 flow, as you can see in our final angiogram here. But, you know, I mean, I think it's a great result. The technique is perfect. I mean, something has to be compromised. It's a really tough situation, and you have to pick your bottle. But I think you pick the one that has bigger territory, but ramus also, you cannot ignore it. I think it's a big size fizzle. But the fact that you, despite the KBI you did and potting, still you have a TIMI 3 flow. So I think, I don't know what I could have done differently, but I would start with DK crush and your bailout strategy was perfect. But I really, I want to applaud you also for sharing the syntax score and how an STS score and how this is kind of played a decision with the heart team, as you are progressing to treat this patient. So Raymond, I might've missed it. What was the LV function on this patient? LV function was normal. It was 55%. And the right was normal? And the right was small non-dominant. Yeah. There's a left dominant system. And actually when we initially started the case, there was discussion of whether or not we would need mechanical support, given that we are intervening on his left system and that his right was small and non-dominant, but given his normal LV function, we actually did a right heart cath or LVEDP, I apologize. And that his LVEDP was normal. So we ultimately chose not to use mechanical support upfront, but we did confirm with the orthopedic surgery team that if we needed to, and in a pinch we could use the right groin as access. No, I agree. You guys did a great result. And I think it was very strategic and smart. The CERC is huge and the LAD obviously supplies a lot of territory. And like Shadi pointed out, you have Timmy III flow in the ramus. So I think it's a very, very good result and not much anyone I think could have done differently. It looked great. It was an interesting case on our part. Oh, go ahead, Dean. Oh, no, no. I think it's great. I agree. I would have cooled a lot. I like that. Maybe would have considered predilating the ramus. You might've done it or not, or all three vessels before stenting. I wouldn't touch the ramus. Got Timmy III flow. I wouldn't think twice. And like you said, you got to pick your battles. Let me ask you, how old is this patient? 67. Yeah. And what are you going to do with DAPT? What's your plan for DAPT? Our plan was to stick with clopidogrel and aspirin. So surgery- For how long, I guess? For how long? Yeah. I think at least six months is I believe what we had discussed. Yeah. I get nervous about these where there's a lot of metal. We get a lot of tertiary center, like you guys, and we get a lot of referrals coming from wherever. And I've seen too many stent thrombosis of left mains coming in and even cardiac arrest in at least my 13 years at Ohio State from a bifurcation stenting of the left main. And most of them have stopped. Most of all the cases actually have been because they stopped doing antiplatelet therapy. So I don't know. That's something to think about. At least as patients age, they're going to need more procedures, more surgeries. We've had cases four years out with stent thrombosis. Yeah. I agree with Dean. I think that's a critically important point for the fellows. And I don't have a lot of data to support this, but in our practice, a patient like this, we would commit to, believe it or not, lifelong dual antiplatelet therapy. And obviously, if they needed surgery or something in a few years or a few months post-stop, then you could probably stop it for a few days. But if they don't have a bleeding contraindication to a case like this, I agree with Dean. That's what I'd be worried about. And we do a lot of left main stenting and we routinely keep them on it lifelong unless there's some really serious contraindication. Yeah. I'll be surprised if we actually said six months. I think we said for sure a year, but it's going to be complicated because it's going to have a lot of surgeries coming. We used to do a lot of indefinite dabs. I don't know. I think we've started moving away from it maybe because we've been more aggressive with imaging. And I'll say a couple things. One is that we did image at the end even though Ray didn't mention. So we have a screen post, both branches. It was interesting. What we thought was interesting about this case was that I think almost nine times out of 10, it feels like our default strategy for these cases are DK crush. And we had called up and planned to do that. And when we realized that we still had really nice access to the LED, we had that balloon there that we could... And it just looks so perfectly sized between that circ and the left main. We thought we could probably... We could switch gears, which was nice. What we thought the advantage there was that if we did have problems with that ramus, we'd have a lot less stent consolidated in that area. And we could even bail out with a T or something like that if we had to. And we thought that could have probably allowed us better strategy for that. So it was an interesting case and something that we hadn't done often, but it was nice to be able to switch gears in the middle of a case like that. So a lot of things to consider for him. Another thing, Dan, I'm running out of time, but one thing that's really important that you guys did. Lombardi points this out all the time is if this patient reached stenosis when we're doing bifurcation left main, the place where they reached stenosis is often the osteocirc. And historically we thought DK crush, protecting, treating the LED like the parent was the right thing to do. But he's starting to challenge that dogma and doing what you did because access to the led is actually easier. And like I had a recent notes, this is going to be in the osteocirc in this case. So I think that we should just start looking at that. Maybe, I don't know if we can look at it scientifically, but you know, DK crush versus that technique that you just did preserving, you know, access to the circ, make it easier if you have to come back. Yeah, I agree. I agree with you. I, we tend to see that, um, osteo incident or just that re-stenosis. Um, and, and when just, I think last couple of bills for adapt, I think you're absolutely right. I think as we're moving forward, it's not really great, like not randomized studies, but I think this DAP for life, which we tend to do ourselves too, and it's a lot of metal in the left main, uh, you're probably right there. Even some of the data when you're looking at dropping, um, you know, the aspirin and maybe continuing these like a more potent P2Y12 inhibitor, potentially with the lower risk of GI bleeding to get rid of the acid, maybe just as effective. So that's going to be important too. I just got one last question for you, Dan, who's going to win the game in two weeks, Ohio state. I mean, that's what I really want to know. You got to tune in and find out chances. I'll be at the, I'll be at the game. It'll be a good game regardless. Yeah. I hope so. I hope it's entertaining. Someone in the chat box has already made their prediction. Last year we lost, so I'm not, I'm not going to. Well, thank you all for really, uh, very, uh, great cases, presentations, discussion, uh, especially to the presenters for submitting cases. I would like to encourage fellows on the call to wait for the new call for case submissions for next cycle and for attendees who attended the call. And, uh, uh, for your, uh, time, I just want to put a plug here. So, so if you are not a member, please, as a fellow is a free force of charge for you. Uh, this is kind of a revamped completely website as well as resources that are free for, uh, members as well. Thanks again to our sponsors, all the founding supporter Abbott, Boston, CSI, Casey and Medtronic. And thank you for the wonderful panel, uh, for making this program successful. Great question. Great discussion and great experience. Great operators. Um, I really look forward to doing more with you together from Michigan, Indiana, and Ohio. And finally, thanks to Sky for giving us this opportunity and for Rebecca, for Ivan and Mitzi from Zoho as well for putting all this work together and for Dr. Doug Dragman for putting this, uh, Sky first, uh, on the map a few years ago. With that, we'd like to conclude and, um, thank you all and have a good night.

Sky First program

Chad Reyes

interventional cardiology

PCI Decision in Challenging Lesions

calcification

bifurcation

dissection

coronary artery disease

left main artery

percutaneous coronary intervention