Case Review, Clinical Research & Data, Complete Revascularization, Protected PCI
Protected PCI as a Practical Approach to MCS in Elective Complex Cases
William O’Neill, MD, presents Protected PCI as a practical approach to mechanical circulatory support (MCS) in elective complex PCI cases. Dr. O’Neill is medical director of Henry Ford Health System’s Center for Structural Heart Disease in Detroit, Michigan. He gave this presentation at the 2021 Transcatheter Cardiovascular Therapeutics (TCT) conference.
What makes a coronary artery disease (CAD) patient high risk? Dr. O’Neill explains that heart surgeons define “high risk” differently than interventionalists, making the heart team vital to management of these patients. “You want to work interactively with the heart team,” Dr. O’Neill explains. “Not being at war with your heart surgeons is incredibly helpful… in a robust program, the referral patterns go both ways.” He provides an example of a patient with severely impaired LV function and complex calcified trifurcation left main, but good distal targets. While this patient is “high risk” for the interventionalist, it is likely that a good surgeon can safely treat this patient with a triple bypass. Conversely, the surgeon’s “high risk” patient with poor pulmonary function and significant angina can likely be readily revascularized by the interventionalist.
Dr. O’Neill briefly review results from the PROTECT II randomized controlled trial (RCT), emphasizing the effectiveness of hemodynamic support in high-risk patients. “Unequivocally, Impella® provides more power than balloon pumps,” Dr. O’Neill states, noting that this translates into fewer hypotensive effects that may lead to renal dysfunction, neurologic dysfunction, and myocardial stunning. He also emphasizes, “If three vessels are treated, there’s a marked difference in the amount of hypotension that occurs. So, the more arteries that you treat, the more complex the procedure, the more likely the patients are to benefit from supported PCI.”
Dr. O’Neill discusses the “enormous clinical benefit” of marked improvements in NYHA class seen post-procedure in PROTECT II. “These patients are some of the most grateful on the planet,” Dr. O’Neill explains, describing how their daily activities were limited by angina or dyspnea pre-PCI. “And at a month, and then at 3 months, there’s a dramatic improvement in their quality of life.”
He concludes with a compelling high-risk, complex patient case study to make these findings concrete, stating, “At the end of the day, all of us have to remember that there’s a patient at the other end of the catheter.” He describes management of this patient, a grandfather who was successfully revascularized and was eventually able to undergo a TAVR procedure and, most importantly, see his grandchildren at Christmas.
“I can tell you, as an operator treating these patients for the last 40 years, it is nearly impossible to get these high-risk patients through these procedures without support,” Dr. O’Neill explains. “And the value of Impella in being able to stabilize these patients so they don’t arrest, they don’t get intubated, they don’t have to have CPR while you’re doing these procedures, empowers you. And so what we’re hoping is that as this technology advances, and as the field advances, more and more of these patients will be able to be treated.”
In conclusion, Dr. O’Neill sees an enormous promise in the upcoming studies in this field and he emphasizes the importance of understanding the basic underpinnings of science while developing the skills that you need to perform HRPCI in these patient as well as developing the team to do it.
Best Practices for Treating High-Risk PCI Patients
Jason Wollmuth, MD, discusses large-bore access and intravascular imaging best practices for treating high-risk PCI patients.
Overview of High-Risk PCI Clinical Trials
Jeffrey Moses, MD, provides an overview of high-risk PCI clinical trials that are setting the stage for PROTECT IV RCT.
MCS During High-Risk PCI and PROTECT IV
Gregg Stone, MD, reviews the evidence for the use of mechanical circulatory support during high-risk PCI and provides an overview of the PROTECT IV RCT.