Ted Feldman MD, FSCAI

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Interventional management of the high-risk patient

• Ted Feldman MD, FSCAI

Evanston Northwestern Healthcare SCAI Fellows
Course Las Vegas December 13th 2007
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Complications

• intra-procedure
• mechanical
• embolic
• stupidity related
• ischemic
• Death
• MI
• Re-revascularization
• hemorrhagic

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• Ted Feldman MD, FACC, FSCAI

Disclosure InformationThe following
relationships existGrant support Abbott,
Atritech, BSC, Cardiac Dimensions, Cordis,
Evalve, EV3, Guidant Consultant Abbott, BSC,
Cardiac Dimensions, Cordis, Guidant, Myocor,
XStentOff label use of products and
investigational devices will be discussed in
this presentation
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Risk Factors for PTCA Hospital Death NY State
Database 1991-94
Holmes et al Circ 102517,2000
When tested in a stent era population of 4063
procedures this model predicted both hospital
long term outcome
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Assessing PCI Risk

• Patient
• LV function
• IABP access
• Renal function
• Valve disease
• Lesion
• Type C vs Type C vs Type C
• Operator

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Assessing PCI Risk
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Assessing PCI Risk
High Risk Anatomy Low Risk Patient
High Risk Anatomy High Risk Patient
Low Risk Anatomy High Risk Patient
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Wong-Baker FacesPain Rating Scale

• Patient
• LV function
• IABP access
• Renal function
• Valve disease
• Lesion
• Type C vs Type C vs Type C
• Operator

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Assessing PCI Risk
High Risk Anatomy Low Risk Patient
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• 72F
• Rest angina persisting in hospital
• ECG non-specific, No elevation of Tn
• LV shows mild anterolateral hypokinesis

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Trifurcation
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DES LAD

• 8F XB-3.5 guide
• PTCA RX 2.0 x 12mm
• DES 2.5 x 20mm

PTCA ramus
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Operator Pleasure Scale after LM 3VD success
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Assessing PCI Risk
Low Risk Anatomy High Risk Patient
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• 69YO male who woke up with right arm and hand
  weakness
• Carotid imaging RICA 20 and LICA 80 stenosis
• MRI multiple small punctate acute strokes in the
  L frontal cortex
• abnormal EKG with possible IWMI and septal MI was
  noted
• ECHO on 3/27 showed apical wall aneurysm and EF
  gt55
• Adenosine Nuclear Stress was abnormal with a
  reversible moderate size defect of severe
  intensity in the apical and anterior region.
  Akinesis was noted in the apical region
• Coronary angiogarm showed 60 LM and diffuse
  distal LAD stenosis
• The LICA was stented with embolic protection
• LM PCI was planned, due to risk of CABG with
  recent acute stroke

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Pre PCI LM stenosis
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Risk for whom?

• High risk for CABG
• Low(er) risk for PCI

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After predilatation, stent circ PTCA LAD
kissing inflation at 12-14atm
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Post PCI
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Assessing PCI Risk
High Risk Anatomy High Risk Patient
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• 89M 4 months ago worsening fatigue, SOB edema
• ECG anteroseptal MI and elevated Tn
• stenosis of distal LM proximal LAD
• mid LAD stenosis
• RCA Circ had mild to mod disease
• EF 30 with akinesis of anterior, anterolateral,
  and anteroapical walls.
• treated medically
• high risk of surgery OR PCI
• Cr 3.0
• Now referred for PCI

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Pre
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Stent mid LAD
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Post 3 stents
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• 89F fully alert oriented, cares for herself,
  lives alone
• Admitted via ED on CP
• troponin elevated to .22 and began to have
  persistent SSCP
• angiography revealed diffuse LAD disease and
  occluded RCA
• EF 70
• Hb 9.0 so transfused

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LAD Pre
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Operator at time of cine review before starting
case
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1.5mm burr
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Equipment Used
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Post PTCA DES
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Pleasure Scale
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• 83YO male
• myocardial infarction and cardiac arrest 1993
• biventricular pacer/defibrillator 2004
• ischemic cardiomyopathy
• EF of roughly 5 on echocardiography
• on continuous natrecor until recently
• atrial fibrillation
• admitted to other hospital 3 days ago with chest
  pain
• NSTEMI, taken for balloon angioplasty
• IABP placed
• unable to inflate balloon in the circumflex
  artery
• Patient then transferred for rotational
  atherectomy

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Operator at time of pre-transfer cine review
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Pre
Rotational atherectomy 1.5mm
burr
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Post rota
stent at 22atm
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Operator at time of cine review before starting
case
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• Lesion Proximal LCx
• Result 90 initial stenosis reduced to 20

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Operator after completing case
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Poor LV Function
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Poor LV Function
Remaining coronary circulation
POST PTCRA
PRE
Post IV NTG Post
Rota Post Lasix
LVEDP 36 mmHg LVEDP
16 mmHg LVEDP31 mmHg
LVEDP22 mmHg
chest pain
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Endovascular CVRS for E2E Mitral
Repair Cardiovascular Valve Repair System
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High Risk Inclusion Criteria

• STS surgical risk calculator 12
• or judgment of surgeon investigator the patient
  is considered high risk due to one of the
  following
• Porcelain aorta or mobile ascending aortic
  atheoroma
• Post-radiation mediastinum
• Previous mediastinitis
• Functional MR with EFlt40
• Over 75 years old with EFlt40
• Re-operation with patent grafts
• Two or more prior chest surgeries
• Hepatic cirrhosis
• Three or more of the following STS high risk
  factors
• Creatinine gt 2.5 mg/dL
• Prior chest surgery
• Age over 75
• EFlt35

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Assessing PCI Risk
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ARTS 12/ Syntax
BARI
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END