Thank you guys so much for having me Tanvir. It's a pleasure. So you guys have seen two incredibly elegant cases. I'm going to show you some slop from the south side of Chicago. Something a little bit a little bit messier. So three vessel disease presenting as a STEMI without cardiogenic shock. You're probably reading the agenda and saying you were promised cardiogenic shock. Just hold your horses. You'll see some cardiogenic shock. All right. 56 year old gentleman presenting to the ED with chest pain waxing and waning for about 12 hours now persistent for about three to four hours. Actually a pretty sad social story. This gentleman was by all reports very functional until he went through a divorce a few years ago and then health care and pretty much everything else went to hell including his diabetes including a lot of things. Blood pressure is 115 over 80. Heart rate is 90. He's satting okay. He's looks quite uncomfortable but he's stating that his chest pain is improving in the ED and this has been brewing now for for about 12 hours. So here's the first ECG. You can see sinus rhythm with inferior ST elevations and some diffuse intralateral ST depression suggesting a posterior current of injury. And and you know not not a whole lot more than that some LVH and so forth. And so he goes to the lab and here's his here's his first picture. And I'd love to sort of break up the presentation and get input from the from the panelists and from Dr. Rob. So there's quite a bit of disease quite a bit of calcium that you can see here. You can see some faint collateral feeling of the RCA. There's some haze in the left main haze in the circumflex. We'll get a better view of it in just a second. We went in with an Ikari guide but we kind of kicked around the idea of just diagnostic catheters because you know infraposterior ST elevation you don't really know necessarily what the culprit vessel is and we thought we would just take a look around. But anyway here's a six French Ikari IL-35. Some more pictures. The left main is certainly hazy and and tight. The LAD is quite diffusely diseased. It doesn't play well here but really in other views you can see that there's lots of little bites taken out of the LAD. The distal circumflex is out. There is thrombus just before that bifurcation and in the LA occultal view I think you appreciate the severity of the left main disease as well as the the hazy thrombotic lesion in the circumflex TBD. Whether the whether the continuation of the circ is out acutely or whether that's something chronic and once again you see the the collaterals. So here's a freeze frame of the of the left main which we perseverated on for for a few minutes and what appears to be a thrombotic maybe culprit lesion in the mid circumflex just before the bifurcation and certainly a calcified Medina 111. I wasn't aware of the 5-1 classification system at the time that I did this case a few years ago so this is just a Medina 111. And so this is the RCA. RCA is occluded as well as expected but with some good collateral. So we'll make this multiple choice and I'd love to put it to the panelists my colleagues and see what what you guys think. So what's your next move? Do you place a balloon pump phone a friend and suggest an emergent cabbage? Something that rarely happens but we always talk about in CCU conference. Probe the RCA to assess if this is the true culprit. There's some things that kind of point towards this being the culprit in terms of lesion characteristics. On the other hand the well-formed collaterals suggest otherwise as well as the calcium in the mid-segment. Femoral crossover and PCI of the circ assuming that's the culprit. PCI of the circ from a radial approach or complete revascularization of the left system right up front just kind of go for broke. And I'll see what you guys think. Before the panelists answer, Sandeep, could you tell us what the hemodynamics are doing and what your EDP was at this time? Yeah so the EDP was 18 and the hemodynamics he's actually normal intensive to hyper intensive at this point. Like 140s, 150s you know. Heart rate hasn't changed much. He's mildly tachycardic. Okay. Tammy, any comments? Yeah I would be making sure that well I would have gone into the lab with both groins prepped ready to go and then I would be phoning a friend as well because you always need more hands on board during these cases. I would still you know talk it's always helpful to talk to surgeons just to say that you've done that even though you're not going to necessarily wait and you'd keep pressing forward but I would get their opinion as well. I would also be considering what kind of support I would want to do because this is a big undertaking and again seeing those collateral that first shot from the left you already see the collaterals to the right which doesn't mean it couldn't necessarily be the culprit but a lot of times those were pretty well developed and those hazy lesions in the CERC and the left main are what really catch my attention. So I'd be considering support and so for me I don't have ECMO available but I would be considering impella access here and then approaching the left-sided lesions. In my years of experience in footpress to me all this comes mostly from the CERC and now collateralizing the right is included so I think the CERC is the culprit. I could be wrong but I think the RCA, the CTO probably and the CERC is probably the culprit. I agree. The proximal disease. Amir or Alex what do you think? Let me ask them a specific question. Would you guys not do MCS and go bail out MCS or I'm essentially I'm trying to highlight the fact is would you hang your hat on that hypertension picture? Hyper. He was he was normal. Yeah I would I first I would do you know those hemodynamics could be misleading. I meant the surprise the EDP is that low to be honest with you if this is acute so that's one thing I'm that's very suspicious. I would do a right heart cath with an EDP that low. It could be masking you know right-sided dysfunction. He could have right atrial pressures. He could have RV failure or RV dysfunction but I would have a low threshold to do a right heart cath and based on those hemodynamics from the right heart cath decide on what support. That would be my strategy. As far as the revascularization I tend to agree with Tanvir and Tammy. I think that the right looks like a CTO to me and if I had to if I was a gambling man which I am I would say the CERC is probably the problem. Okay well while we were prepping equipment for the left I said we've got a guide in here let's just go ahead and scratch at the the RCA. We scratched that with a micro catheter and a hydrophilic wire and it was like a you know like a rock. So now we're set up we've got a I think an EBU guide yeah EBU 375 guide in. Patients now having a little bit more chest pain hypertensive to the 150s and 160s. Oxygenation is within normal and we you know like suggested we we guess that the circumflex is the is the problem but figure there's no no harm in just scratching at the RCA making sure that it doesn't just sort of fly across. So we've got a six wrench EBU 375 guide stayed with the radial approach and a run-through wire in the CERC and the OM and wired the LAD to protect it with a PT2MS and started ballooning the CERC see if we can just kind of you know and this was honestly this was sort of motivated by the fact that he's complaining of a little bit more chest pain. He was very sort of comfortable coming into the lab and all of a sudden started having a little bit more chest pain so we decided to move quickly here and balloon the OM and see if we can restore some flow in that in that circumflex but you can see that that that left main doesn't look doesn't look great at this point and now he's having some polymorphic VT so groins are prepped threw in a mega balloon pump and said we're probably going to need a little bit more than that but just go ahead and you know get what we have in quickly deployed a stent in the OM and now he has he turned very quickly Amir I think your your comments are prescient 18 was probably misleading we quickly dip dip the ventricle he has fulminant pulmonary edema now and gets gets innovated. So now we start thinking about what we're going to do you know the left main looks like it's shutting down and the decision was to what to do next with the left main we decided to just go ahead and control the left main we've got a wire in the LAD put a 3 5 by 15 DS into the left main with a trapped wire there's a little bit of shift still some flow in the in the LAD and at this point we're thinking about just upgrading the the balloon pump to either an impella or consider going to to ECMO you know here's our here's our choices I think practically speaking tandems not really an option if the aortic valve can be can be used we're pretty sparing in our use of tandem heart at least as a LAFA configuration in our lab we're much heavier on impella and ECMO and he's already got a balloon pump in and the balloon pump was thrown in more thinking that you know he's got some some polymorphic VT but maintaining his pressures in between the little in in between the little bursts pros and cons obviously for for all of these devices we are very fortunate to actually have ECMO in our lab and all the interventionalists cannulate independently we have perfusion help us sometimes and you know most of the time not most of the time it's our cath lab nurses that are cutting circuits for us and they have quarterly competencies and so forth so it is incredibly useful to have that in your lab but recognizing that most labs don't have that I think impella would have been the the choice for for for most of you know most operators in this in this situation any thoughts why do you choose an impella say it again why do you not choose an impella versus an ECMO why did I choose an impella why didn't I why did you not choose an impella well can I hold that answer for for the next slide okay so this is what happened next PEA is is what happened next so you can see Lucas compressions basically it went in in the span of about a minute and a half 90 seconds to maybe two minutes to to shock resistant VF and and PEA and so that's the that's the next shot which is suboptimal and the decision was was made for us so we cannulated during compressions total cannulation sequence without integrated perfusion only took about seven eight minutes 17 French art obviously we didn't put stitches in 17 French arterial 25 French vented venous cannula all the way up into the the right atrium four point leader one liters of flow at 5,000 rpm and some pulsatility with a balloon pump you know triggering off the the rhythm which we never lost and now the map is about 70 to 75 and we get to work obviously ECMO is great for for restoring a perfusing blood pressure but there is the concern of increased LV wall stress sub into cardio ischemia LV distension and for somebody like this I think that you know they're gonna stay on pump for a while aortic root thrombus is not infrequent if the aortic valve remains closed for the duration of the cardiac cycle so there's a lot of sort of playing around with the the circuit after it goes in to allow some ejection of the of the left ventricle okay so back to the left main bifurcation we've put a stent across the LAD and I think you know it's it's worth a discussion of provisional just fenestrate into the LAD and and sort of see if that's reasonable reasonable result we thought that that was highly improbable that that was going to happen and so that brings us to to coolot beautiful images from dr. Rob's article from a number of years ago or DK crush and I know DK crush gets a lot of points at every meeting and every discussion but done right my personal opinion I think that coolot gives you great great results particularly if you're going to commit to doing the extra kissing balloon inflations and so forth this is for your OCT outcomes of reconstructed I mean this gentleman got stents everywhere as part of his pre-transplant workup for kidney and you know beautiful reconstructed carina four years later by by OCT this is a different case obviously okay so back to this case so now we're on pump we've got some native heart function we've got a balloon pump we've got a an ECMO circuit going with about 4.1 4.2 liters of flow and we decided to go ahead and convert this to a coolot since we've already got a stent across the the LAD ostium we put up three five three five potted with a four five a couple of kissing balloon inflations Ivis and this is the this is the final result the ECMO cannula was secured the balloon pump was secured we put in anti-grade limb perfusion and a PA catheter from the right IJ it's got a pacemaker in as well and he went to the CCU with that you know the epilogue this is actually pictures we took after the case a lot of a lot of equipment and just he just had a very extended hospital course but he was able to get off of ECMO and balloon pump within about a week to 10 days extubated and and then just sort of had a very complicated hospital course but I think you know considering the circumstances we got a decent result a lot of residual disease in the circ and the and the RCA that that needed to be dealt with later on as well so that's what I have for you I'd love to hear some comments and some opinions about it I just phenomenal case I have a couple questions one is did you end up putting the right heart cath in after you put him on ECMO yeah yeah after everything after after the dust settled we put in a right heart cath from right IJ anti-grade limb perfusion you saw that his his femoral 17 was probably all it was going to take for an ECMO cannula so definitely needed some some anti-grade perfusion for that case the other question because there's a couple of tidbits obviously your patient was was crash and burn so we often put in the the anti-grade stick first and with the exception of your case like that it makes your life much easier second thing is did you can you talk a little bit about your venting strategies and options in these patients I noticed you kept the balloon pump in when do you choose to vent with the balloon pump versus an impella and what are the criteria you're using for venting right now Sandeep at your place yeah that's great both awesome points you know I think a couple of things that we would have done a little bit differently if this wasn't such a crash and burn case now we sort of separate the cannulas the arterial and venous cannulas and put it in different legs just so that we don't have crowding that's that's number one we put it both on the same side the the comment about putting in anti-grade access at least putting in a micropuncture sheath or a wire anti-grade before you get retrograde access makes your life so much easier because once you've got somebody on jet fuel with a 17 or 19 French arterial cannula it can be very challenging to actually get into the CFA or the SFA with anti-grade limb perfusion so it did take a little bit of a little bit of time we got into the SFA with it and we were able to to perfuse and as far as venting by the end of the case he actually had contractility he was opening his aortic valve so we left the balloon pump in if there's minimal contractility and the aortic valve isn't opening I think it's it's much preferable to to put it in impella and that's sort of our practice nice for those of you who do ECMO wouldn't it be nice if we had purpose-built cannulas for cardiologists in the cath lab for example if we had an ECMO cannula that you could actually just put an impella through or an ECMO cannula we could do our PCI through I think those are coming there are some companies out but I think you saw you saw Sandeep's case we do those too I think that ECMO the future of ECMO will be in the cath lab and to that end we need to start having you know industry help us design devices that are purposely built for cath lab and for intervention cardiology yeah my one comment is that you know with that amount of disease I know the EDP is low to begin with but I personally don't know that much disease I thought of an impella first yeah totally fair yeah I just want to take a second Sandeep to a compliment you on the case I mean it was a really tough case I mean this the choice between you know very tough outcome versus near certain death so I think you did a great job congrats to you and the team for helping this patient I also want to take a second to highlight to people that sky stage B which is what your case was is a very nebulous stage I think we are often tricked in the cath lab many of those who don't do who are not shock enthusiasts or like doing too much shock we end up seeing this more often than we do and we often think that restoring the continuity of God restoring the antigrade flow through a coronary is the right thing to do but oftentimes what that does is if you'd have a high EDP which was not true in your case but for other reasons you end up not having coronary perfusion and you put them into this spiral and they end up having this negative spiral when they have ventricular failure and start circling the drain so not hanging your hat on the blood pressure variable and trying to be holistic in your understanding getting all the information you can I think I may have mentioned getting a right heart cath even before you commit to a revasc technique I think those are really critical in patients with early stages of cardiogenic shock yeah thanks for that stars there's some comments in the in the chat as well dr. Ian Gilchrist pointed out that if the RC is acute all three vessels are unstable you know I was I was kind of hoping for an easy win and did not get an easy win but always worth poking at the RCA just to make sure I drew was asking about Lucas in the cath lab yeah Lucas you know you can choose between compressions or doing your case but it's rarely both unless you're dealing with very specific angles you're definitely not going to get orthogonal angles we briefly tried trial the the Zoll device which is touted as you know much more easy to see through but it's you know it's it's kind of like looking through a prison cell I mean there's bars everywhere and you know I didn't I didn't find that to be all that much better and I wonder what you guys think and does everyone have Lucas or a different device in the cath lab I think the see-through Lucas does work I mean I mean it prevents your staff from getting floored obviously the eye is pretty much higher you may make the visualization and going through the procedure well but in the situation where my left brain is shut down and I need to do it as see-through Lucas is help I think I have enough sense to know where to put the stent in like a totally fluid left brain and I've had survival from that but you're right I mean you have you cannot make that bumper smaller you know to be honest with you because it needs a tumble to go down to give you good compression I don't know what solution is but I think that that the see-through Lucas is probably the way to go I know we're in the top of the hour so I'll request dr. Atkinson to close us out to be respectful to everybody's time yeah so thank you to all our presenters those cases were amazing with great results and kudos to you for pulling off these excellent cases so one more thing that says another last comment is from the chat is pre-planning to full support before PCI avoiding the crash and burn especially if you're a single operator but I think anytime you're going into these cases if you have that moment of hemodynamic stability just stepping back aside and planning it out and planning your cath lab because also prepping the team and making sure that everyone's prepared for the next stages that may come is really important as well so thank you to all of our speakers thank you to sky for putting this on and I think that wraps it up unless there's any other comments or questions thank you very much for joining us today well thank you very much

coronary artery disease

STEMI

ventricular tachycardia

ECMO support

cardiogenic shock

emergency intervention