Life by a thread: LM PCI made safe with Impella
Consult this Twitter case concerning a frail elderly patient with severe LV disfunction declined for coronary artery bypass graft surgery
Impella assisted unprotected left main PCI with RCA CTO in a frail elderly Patient with severe LV disfunction declined for CABG
This case was originally published on Twitter by @gdodo92via #CardioTwitterCase
Clinical presentation
Here we present the case performed at the Hospital Samaritano of São Paulo, Brazil, of a 82 year old female with hypertension, diabetes, low BMI, frailty and previous coronary artery disease (1 DES to LAD and 1 DES to LCX in 2013 and 2 BMS in the RCA in March 2018) presenting with progressive symptoms of shortness of breath (NYHA III) and typical chest pain (CCS 3) in the past 2 months. Upon admission at our Institution (Hospital Samaritano, São Paulo, Brazil), she exhibited signs of volume overload and her Echo assessment demonstrated loss of LV function (from 50% in March 2018 to 30% in August).
Case Management
After clinical compensation, she was referred for cardiac catheterisation performed through Left Radial Artery (Movie 1) revealing an ostial in-stent RCA CTO (supplied by grade 3 retrograde collaterals) and a Severe ostial-proximal LM calcified stenosis extending to proximal LAD. Heart team was consulted and, due to a high frailty index, severe LV dysfunction and age, the patient was deemed ineligible for CABG, so then, MCS assisted unprotected LM - LAD provisional PCI was proposed.
The procedure was performed with conscious sedation and bilateral ultrasound guided puncture of the common femoral arteries. The Left Femoral Artery was chosen for the Impella because of its bigger diameter (6,5mm vs. 5,5 mm in the RFA, which received a 7F sheath) and both accesses were obtained uneventfully (except for a fail in Perclose sutures to deploy in the LFA even without calcium in its anterior wall).
Impella CP was positioned in the LV and a JL 3,5 7F guide with Side Holes catheterised the LM. A Universal II 0,014’' Guide Wire (Abbott) was advanced in the distal LAD and a PT2 MS 0,014’’ Guide Wire (Boston) was advanced in the distal LCX. Pre-Dilatation was performed with a Non Compliant 3 x 20 mm Trek Balloon (Abbott) from the LM to the LADp (proximal under expanded stent edge) up to 24 atm (full balloon opening) and, after confirming non flow limiting dissection or No Reflow, a 3,5 x 24 mm Synergy Stent (Boston) was positioned from ostial LM to proximal LAD previous stent edge and deployed at 14 atm. For Post-Dilatation a Non Compliant 3,5 x 12 mm Trek Balloon (Abbott) was positioned and inflated at 20 atm distally and 28 atm proximally in the LM. TIMI 3 Flow in both LAD and LCX were confirmed and Guide Wires were recrossed for Kissing Balloon with a 2,5 x 12 mm Semi Compliant Emerge Balloon (Boston) in the LCX and the NC 3,5 x 12 mm Trek Balloon in the LAD with high pressure sequential inflations and a simultaneous kissing at 6 atm. It is important to remark that during all balloon inflations the Blood Pressure that Ranged from 150 - 170 x 80 - 90 mmHg dropped to 110 x 100 mmHg with full Impella Support, relieved only by coronorary blood flow restoration.
IVUS catheter Opticross 40 mHz (Boston) with automatic pullback from the LAD towards the LM revealed a well apposed and expanded stent in the LAD with a Minimal Luminal Area (MLA) of 7,8 mm2 and a LM with an also well apposed and expanded stent with a MLA of 10 mm2 with full ostium coverage. Angiography confirmed the procedural success and LCX IVUS was not performed (Movie 2).
Haemodinamic stability, absense of arrithymias or decompensated Heart Failure allowed for weaning and withdrawal of the Impella minutes after the PCI (Movie 3). Since the Perclose device previously failed to deploy, Angio Seal VIP 8F (Terumo) and manual compression were used associated with contralateral injections confirming antegrade blood flow in the LFA and no contrast extravasation. The 7F RFA sheath was removed with Angio Seal VIP 6F (Terumo) with success.
The total volume of contrast was 75 ml and the patient evolved well and asymptomatic and was discharged 3 days later.
This case highlights the importance of Myocardial Support in the setting of a Complex PCI in which any complication would be deleterious and probably fatal and how access closure can be dealt with bail out strategies when suture mediated devices fail (as an alternative to previously described Double Angio Seal Technique).
Original tweet and Twitter discussion
82yo lady with CCS 3 angina and NYHA 3 HF with 30% EF and an Ostial RCA IS CTO (previous BMS). Declined for CABG. Upfront MCS + IVUS Guided LM - LAD PCI@mmamas1973@aspergian1@evandrofilhobr@tietamedeiros@ekgpdx@fabio_pinton@GreggWStone@sbrugalettapic.twitter.com/YcwM5BRIea
— Gabriel Dodo Buchler (@gdodo92) August 27, 2018
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