Alex Truesdale, Interventional Cardiology in Northern Virginia. So I'm going to talk about a case of a left main bifurcation intervention in a cardiogenic shock with percutaneous ventricular assist device support. Here are my disclosures. So starting off, this is a 60 year old gentleman with the usual cardiovascular risk factors, hypertension, hyperlipidemia, diabetes, who initially had some waxing and waning symptoms for approximately one day, presented with a tachycardia, hypotension, volume overload, and elevated lactate. EKG showed interior ST elevations and global markers of global ischemia. And this was the initial diagnostic angiogram with no significant right coronary artery disease. And these very subtle left main distal bifurcation findings, I'm kidding, Medina, I added an extra one to the Medina, one, one, one, one, left main LAD ramus, circumflex, trifurcation, subtotal occlusion with Timmy one flow. So at this point, he's, like I said, heart rates, 100s, blood pressures, 90s, and lactate of two. And a balloon pump was placed at the outside facility with a select after select ephemeral angiography and aortic iliac angiography was performed and patient was transferred at this point for heart team consultation and review. And one little, I'm on the, I'm attending in the cardiac ICU this week. So my house staff have heard my soapbox about this, that patients are transferred from one facility to another for multidisciplinary comprehensive heart team evaluation. They're not transferred for CABG, they're not transferred for PCI, they're transferred for evaluation of CABG versus PCI versus medical therapy versus palliation versus heart transplant versus a VAD. And I think by now there's so many examples and most of us really function within this heart team evaluation where we really wanna look at the patient from full perspective and with, as we all agree, a patient at the center of the evaluation. And so initially a patient that is stable at this point, looking at all the different options and weighing the different factors that may fade for surgical revascularization versus percutaneous revascularization versus medical therapy versus palliation versus heart transplant or a VAD. And some of this is gonna depend on the operator, the anatomy, the patient, the facility, individual experience, and of course, our evidence-based guidelines. So heart rate was, again, still 100s, blood pressure had improved to 100s, balloon pump was one-to-one, ejection fraction was 30% by echocardiography with significant interior wall hypokinesis. The patient was planned for surgical revascularization. And I think at some point there was a question about viability and there was a desire to perform a cardiac MRI, and for which purpose the introverted balloon pump was removed. And this was the subsequent results. So you're probably asking yourself, I thought this was gonna be a presentation of cardiogenic shock, and now it is a presentation of cardiogenic shock. So now you have a patient that's profoundly hypotensive with global ischemia. We know what the anatomy looked like before, and the question is, what does the anatomy look like now? Probably not better, and what to do. So I think before, if you were talking about PCI, it would have been complex due to left main bifurcation and probably elevated risk. Now I think in cardiogenic shock, it's very high risk and very complex. And this is a nice sky document from a couple years ago. So I'll kind of buzz through this, and then we can get to the bifurcation piece. This is a great diagram from a number of years ago from Naveen Kapoor that really reshaped how I look at the cardiogenic shock, instead of just focusing on coronary perfusion, really securing circulatory support and ventricular support first, so that you can maintain the hemodynamics, essentially the same way the surgeons would do before we move on to percutaneous coronary intervention. So, and also, if you have a vascular complication, which is by far more common than a coronary complication, then it really doesn't matter most of the time what you do with the coronary. So ultrasound guidance, micropuncture, selective angiography, and upsizing. And in this case, went in with Impella first. Again, really just highlighting the importance of meticulous vascular access, and there's some nice reviews on this topic, and I actually made this five-minute soup to nuts video with the link there in a box file for anyone who wants to look at that at a later time. And so what I would say is, let's assume what the anatomy was before, before I show you what's next, what do people think from a bifurcation perspective? If you're going into the cath lab, because I didn't know what I was thinking, what are you thinking, you know, heading in at this point? Yeah, I think Dr. Rab had a comment. Let me pick on him first to see what his thoughts were. Alex, it's probably too much work to show that audio card review again, right? It's too much slides back. I can scroll, let's see. If you don't mind, I think that, yeah. Okay. Medina11111. No kidding. So one thing, who would do, why really study a balloon pump in a situation like this? Where'd that come from? I mean, I'm just curious, because that's the wrong message, you know? Yeah, just to let me in disease and just cut off a balloon pump to do it. I mean, I'm not sure. I mean, maybe I'm not in the shoe right now as to who would make the decision, but no, I totally agree. And some of this, again, and this partly the message I said before, and I've been emphasizing all week here, you know, when a patient is transferred for CABG, I always say they're not on the CT surgery service. They become a CT surgery patient once they cross one millimeter into the OR. When they're one millimeter, until they actually enter the operating room, they are whatever service they're on, they're your patient. So I think sometimes we get wrapped into doing things, whatever the surgeons may suggest for surgery, but they're not managing the patient at this stage day-to-day. They are, you know, intra-op and post-op. So I think that's where some of that came from. I completely agree. My viability study is, are there R waves? Is there electricity going through there? And is there thickening on echo? And then also, you know, viability is not binary. It's not zero and a hundred. And actually, I just learned this a number of years ago, different facilities on cardiac MRI even set different cutoffs for 50%, 60%, 70%. So you may go from one facility to the next, and you're viable or non-viable just based on what the facility cutoff is, which I didn't realize until a number of years ago. But the other important thing, did they check an EDP? That's very important for me. And was there a heart attack indicator? Yeah, I had the same question as well on the EDP. So Alex, tell us what you did. I don't want to cut you short on your PCI masterclass, but tell us what you did. Yeah, so again, I think, you know, some of looking at how do you approach your bifurcation obviously depends on, you know, is it a bifurcation, trifurcation, quadrification? You know, where is it? And we've already, you know, established what this one is. And I think this may be a little bit different in different facilities. You know, obviously the anatomy and the patient, you know, I bring this up, I sort of showed the diagram from Naveen before, and I really advocate, once you've secured the hemodynamics, you can take a deep breath and do a good job. So this concept of the immediate double barrel shotgun so that you can pat yourself on the back and say you revascularize the patient, but you really know there's not going to be durability is really not the way to approach it. And so, you know, there's not going to be durability is really not the way to go. So this was the, you know, initial angiogram. So the flow is even worse. So secured hemodynamic support first with Impella CP in this case. Second was wire control, you know, rapidly wiring all three branches. Frankly, I always, you know, say there's the, you know, the first point of stress is getting the circulatory supporting. Second one is, you know, wiring. And then once you do that, you balloon your restored flow, you can take a deep breath. And then it's just a matter of, you know, thinking through the strategies. So intracoronary imaging is pivotal. I'll point out that is now a class one indication in the European guidelines for a small group of lesion subsets, but that does include left main. And, you know, you can see just a snapshot of the data that is now accumulated for each of the lesions, but this really should become, you know, class one in the next iteration of the US guidelines, which I anticipate. So again, different people have different techniques. I've actually had a crazy string of about seven Impella left mains in the last six weeks. And I've transitioned kind of to DK Coulat. You can see the dimensions of the stenting. And I think the key thing is all of these techniques where there's DK Crush, DK Coulat, require meticulous application of all of the steps. I have this guidance, kissing balloon inflations, proximal optimization, you know, the double kiss. And here you can see that, you know, whether it's the Crush or Coulat, there are lots of steps and you have to remember all of the steps. And if you're meticulous, then I think, you know, accumulating data suggests we can complete with CABG. Also knowing sort of where the pain points are. This was a great, you know, Sky Online document that looks at, you know, some of the very minutiae of performing, you know, left main and bifurcation PCI about where's the discal crossing. How do you make sure you're not under a stent strut? You know, how are you performing your, you know, your Crush. And so this is for good, you know, reading afterwards. Also important to know when you're doing your pot, where the balloon markers are. So these vary by balloon. So know what balloons are in your shelf and where, what that's gonna look like. Also understand how to do the proximal optimization technique right. And when I'm saying always sweat the small stuff, again, this is how we're gonna realize surgical equivalent outcomes. For recrossing after, you know, Crush, whether it's, you know, a DK Crush or DK Coulat, you know, knowing which are your low profile balloons. I like to start with small, low profile balloon to create my pilot hole. And then you can escalate from there. I find whenever I skip steps, I just create more steps for myself. And then sometimes having a dual lumen micro catheter, I think is an invaluable asset on the shelf for, you know, depending on angle. And I've really increasingly used this for a lot of applications. So data wise, you know, like I said, I think most people probably doing DK Crush. I think this is really interesting flow dynamic data about Coulat, DK Coulat and DK Crush that was published. And, you know, this was a one year results of the route trial. This was not in left main, but interestingly showing, you know, lower target lesion failure, revascularization, target vessel in mind, cardiac death in the DK Coulat versus DK Crush group. So in the end, Impel assisted, IVAS guided, left main LED, circumflex, DK Coulat, bifurcation PCI with just balloon angioplasty to the ramus. You can see the expansion of the, you know, stents and proctomal optimization, kissing, balloon inflation, as I mentioned. And then the case is not over, right? So we're not done yet. And I always say, you know, everybody wants to eat dinner. No one wants to cook. No one wants to clean up, but nobody leaves the table till everything's done. So peel away sheath is removed, run off angiography performed to ensure, you know, limb perfusion, Impella was sutured in place. Perclose was cinched, but not locked. In this case, I placed a mattress suture, additionally. Also, I always like to get a PASatin lactate coming in the lab and coming out of the lab. Leave the SWAN in for ongoing guidance. Impella came out the next day. And then, you know, dual antiplatelet therapy, GDMT optimization, repeat inpatient echo. I always like someone to have an echo before they leave the hospital. Patient went home a couple of days later and EF was 40, 45% at like 14 months. Follow up. So most PCI does not require hemodynamic support. Shock, I would say, is different. Secure the hemodynamics first. So secure the LV circulatory support. Then you can look at coronary intervention. Always be meticulous. We have to be as good as, or better than the surgeons, both for immediate, short, medium, and long-term. And that's going to require not skipping steps, intra-coronary imaging. And then again, with MCS weaning, this has to be driven by serial hemodynamics in the cath lab, metabolics such as lactate, and as an ongoing process that follows on in the CICU. That was a fantastic result. Beautiful stenting there and management. Now, the hemodynamics are extremely important. And did you start off the case by putting in the SWAN? Because I think it's an important part that, you know, we're all forget about and don't want to forget to do that at the beginning. Yeah, I did. And this, in this case, I put the impella in first because I, you know, blood pressure 60 is crashing, not doing so great, but then afterwards I did put the, you know, and actually, so sorry, here I did that secured wire access because I sort of already knew what I was getting into and then did the, you know, and then did the SWAN. And I did skip over some of the hemodynamics stuff here since this was bifurcation webinar. So I wanted to focus a little bit more on that, but it is a good, you know, a great point. And even if to me, some of these things, whether you do it first or last, I just say you have to do it. So some of these things have to be done before you do the, leave the cath lab. I think there's reasonable debate about where in that it happens, but there's not reasonable debate about leaving the cath lab without having done it. And certainly to me about making decisions about whether Impella comes out or not. And then, like I said, that's why it's good to have some initial early and later PASATs and then Lactaid too. And if for nothing else, then you have a trajectory to help you later in the cardiac ICU. Yeah, it's such a great point because the care doesn't just stop after you get through the PCI, it's the management after. And when you're putting these in these devices, you also have to think about the post care and how you're going to go about approaching it and setting up your ICU for success too. Well, Alex, can you go back to the DK Kulot slide just to go to the steps for the audience? So, because not many people do it now, but I think that's a trick where you learned that you had a slide showing the step in this one. Obviously, step one is to wire access to all branches. In my case, I wired the LAD, the CIRC and the RAMUS, but let's just assume this is LAD and CIRCUMFLEX. I typically, so I'll go and balloon both branches and then I'll do intravascular imaging. So I already have a sense of sizing and then you're going to size your stent. So for the DK Kulot, unlike the CRUSH, you're still going to take one of your branches. And I've read interesting debate about whether you do the CIRC or the LAD. I think some of it depends on which vessel is larger, what the bifurcation diameter. So I don't think you can flat out pick one or the other, but oftentimes it'll be the CIRCUMFLEX. So the stent, the CIRCUMFLEX back to the left main, and then you're going to do proximal optimization technique. Some of that is not reflected here. So you do proximal optimization. I'll do a KISS there again, and then you're going to open up the cells with those low profile balloons. Then you're going to go in with your next stent in from the left main LAD. Again, cross the cells and rewire, balloon both branches, and then do your proximal optimization. And there's actually a good app on, I think that Mount Sinai puts out that has a good iPhone based app, Bifurcate, B-I-F-U-C-A-T-E. Yeah, B-I-F-U-R-C-A-I-D. That is really nice. And so, if this is not something you do regularly, just flip through on your phone or have a colleague or someone on your team flip through. This doesn't cover all the steps, but I think the key things is the rewiring, the cell crossing, proximal optimization, kissing balloon. If you're new to this and if you're going to forget to pull wires, tell someone. If there's important steps, remind me this, write out the steps in advance, use the app, whatever it is. Definitely get help because you don't have to necessarily remember everything yourself. I think all great points. And just like you go to the heart team and the ICU and how important that was for this, I think sitting down before these cases when it's not a shock case and you have the luxury of time prepping your team, so telling them those important steps, like, hey, remind me not to pull the wire. You're so right because a lot of times we get so involved in the case. The other thing is, you know, getting a sterile pen and writing down the steps and then you can cross them off as you go through. And then you feel somewhat of an accomplishment when you get over halfway through. Go ahead. Sorry, go ahead. Go ahead. No, no, go ahead, please. Oh, no, that was, I think the other- I was going to offer a practical suggestion is I actually have gone to the Jack Intervention articles, I think written by Dr. Abb and other leaders. And I just have printed out their figures and stuck it to the bottom of my monitor sometimes and I'm absolutely, want to be absolutely certain. I want to make a couple of points. I think Ajit had a question in the chat asking how far back to hang the first tent? I'd say, like Dr. Abb said, enough to pot, but that doesn't have to be the first tent. The second, you don't have to have two barrels overlapping all the way, but whatever the proximal limb is has to have enough that you accommodate your shortest balloon. In our lab, it's eight, some labs may have six. The other thing I want to say is it all depends on which branch you're willing to give up. For DK Crush, you always have a wire down the main vessel, whereas for Coolhut, you always have a wire down the side vessel. So if you're willing to give up your main vessel wire and treat the circ first, I think that's why Coolhut is superior there. But if DK Crush, the positive is you always have a wire down the LAD no matter what.

bifurcation intervention

cardiogenic shock

ventricular assist device

DK Coulot stenting

hemodynamic support

intracoronary imaging