Escalation Therapy, Protected PCI
Sandesara: Heart Team Success Story
Pratik Sandesara, MD, shares a complex “heart team success story” in this Coronary Artery & Myocardial Protection (CAMP) Community Case Competition (COMP) presentation in October 2022. Dr. Sandesara is an interventional cardiologist at Emory University Hospital.
The patient in the case review is a 76-year-old male presenting for pre-renal transplant cardiac evaluation with symptoms of dyspnea on exertion and NYHA class III heart failure. He has heavily calcified three-vessel coronary disease as well as moderate mitral valve regurgitation and severe aortic stenosis. The case is sent for heart team discussion and the patient opts for coronary artery bypass surgery and aortic valve replacement. However, two days prior to planned surgery the patient is admitted with acute decompensated heart failure and progressive cardiogenic shock requiring inotropic and vasopressor support and continuous renal replacement therapy (CRRT).
The patient undergoes balloon valvuloplasty (BAV) with Impella CP® support with a plan for subsequent revascularization. The LAD has a very tight calcified lesion that cannot be traversed so the team turns its attention to the RCA, performing intravascular lithotripsy (IVL) and stenting before returning the patient to the ICU. After consultation with the advanced heart failure team, they implement a plan for transcatheter aortic valve replacement (TAVR) with Impella 5.5® with SmartAssist® support. “I think he was too sick for us to do all this with a CP in place,” Dr. Sandesara explains, “so I think escalation of support was really helpful from a coronary revascularization standpoint.”
After successfully deploying a Sapien 3 valve, Dr. Sandesara describes the plan to “retackle the LAD now that he has more support, he’s got the new TAVR valve in, so hopefully he’ll be a little more stable for more aggressive options to tackle the LAD.” He then describes how he used dissection/re-entry to go around the calcified LAD lesion to accomplish stenting. With both tortuosity and calcification complicating the circumflex, Dr. Sandesara and his team decide to leave the circumflex alone. Four days later they successfully remove the Impella 5.5. “I think this was a great heart team success story,” Dr. Sandesara concludes.
In the conversation that follows with the CAMP faculty panel, Raj Patel, MD, describes the case as “a heroic save.” Ali Ziad, MD, comments “What you showed was a 60-day course of managing a patient instead of a problem,” noting how Dr. Sandesara and his team progressed from replacing the valve and then over time escalating to tackling each problem most likely to cause shock. “Many times, I think, perfect is the enemy of good,” David D’Alessandro, MD, adds, “and stopping at the LAD was clearly the right thing to do and you might have gotten into trouble if you tried to be too aggressive with that patient.”