HEART-TEAM APPROACH TO

COMPLEX CORONARY ARTERY

REVASCULARIZATION

Akshay Khandelwal, MD FACC FSCAI

Director, STEMI program and PCI Quality, and

Director, Outpatient Cardiovascular Services, Henry Ford Hospital

Clinical Associate Professor, Wayne State University

President, American College of Cardiology—Michigan Chapter

Chair-Elect, American College of Cardiology Board of Governors

@KhandelwalMD l akhande1@hfhs.org

MSTCVS 53rd Annual Meeting l August 11, 2018

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It’s all about the team, the team,

the team …• Heart team for revascularization is a Class I

recommendation by intersociety guidelines

• Hybrid metrics– Institutional revascularization mortality

– Institutional revascularization bleeding, nephropathy, CVA

• Bundled payments for complex revascularization

2

Case Presentation #1

• 65 yr, Male, 5’8”, 275 lbs

• PMHx: HTN, HPL

• Non-smoker, works full time, married, 2 children

• Outside Hospital (OSH) with CP/SOB– 3 am symptom onset

– 7 am ER arrival

• Vitals:– HR 110s

– BP 90s/50s

– 92% (RA)

• EKG: diffuse ST depressions, (reported)

• CXR: B/L pulm edema (reported)

• Laboratory:– Cr 1.3

– WBC 12.3 Hgb 15.6

– Lactate 4

– Trop 0.49

– BNP 2336 ng/L

“The Transfer”• 3 am symptom onset

• 7 am ER arrival @OSH– Cath/Intubated, Impella

placed

• 9:45 am transfer process initiated (1 hour drive)

• 1:15 pm arrival to HFH

• Vitals– HR 80s

– BP 68-89/62-73

• NorEpi 0 15 mcg/kg/min

• Lactate 4 1.8

• Trop 0.40 >100

• Cr 1.3 2.06

– ALT 109 / AST 478

– A1C 6.5

What are the HEART TEAM

recommendations ?A. Escalation of mechanical circulatory support (MCS) & percutaneous revascularization

B. Continue current level of MCS & PCI

C. Surgical revascularization w/ back-up LVAD

D. Durable LVAD work-up

E. Supportive Care

RA 13

RV 28/19/20

PA 35/29/29

PCWP 18

PA Sat 54%

PAPI: 0.3

CO: 3.34 L/min

CI: 1.54 L/min

CPO: 0.73 W

RA 13

RV N/A

PA 32/16/22

PCWP N/A

PA Sat 69%

PAPI: 1.23

CO: 8.7 L/min

CI: 3.7 L/min

CPO: 1.29 W

Date of Admission 48 Hours Post-PCI

Hospital Course• Remained dependent on ECPella

• Adv HF working up dLVAD

• (Day 6-8) Profound GI Bleeding (16 units

PRBC/72 hrs)

• AKI/ATN (Cr 7.2)

• Supportive Care (Day 9)

Discussion

• How best can teams manage ASCAD with

cardiogenic shock?

• Was a poor outcome inevitable? Should

supportive care have been offered earlier?

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Case Presentation #214

• 52yo M presents with

chest pain and

shortness of breath for

one week,

progressively

worsening.

• Risk factors: – Active Smoker 1PPD for

30 years

– Family history of premature CAD death (mother died in her 40’s, father in early 50’s, and sister in her 40’s)

Physical Exam/LabsVitals BP 110/70 mmHg, HR 102, RR 12, O2 98% RA, BMI 27

General: No acute distress, normal mood and affect, AAOx3

Cardiovascular: normal s1, s2. Tachycardic, regular. No murmurs. JVD not elevated

Respiratory: mild bibasilar crackles bilaterally

Extremities: warm, no edema

10.1

16.1

48.3

239

140

3.7

102

26

13

1.2598

Troponin 1.08 -> 0.95 -> 0.99 -> 0.78

BNP 673

LFT’s normal, albumin 3.8

LVEF 19%

Akinesis of the apex

Normal RV function

No significant valvular disease

Apical thrombus

Mid RCA 95%

Serial tandem lesions

in rPDA

RPL3 90%

Prox LCx 80%

RAMUS 80%

OM2 100%

Prox LAD 100%, Large diag 1 100%

Thallium 20 minutes, 4 hour, 24 hour images

Entire

myocardium

viable except

basal inferior

wall

20 minutes

4 hours

24 hours

Heart Team Meeting

STS Score: Mortality 0.7%, Morbidity or Mortality 11%

Syntax 1 score: 69.5 Syntax 2 score:

PCI 4 yr mortality 57.5%

CABG 4 yr mortality 3.2%

Tx recommendation: CABG

What are the HEART TEAM

recommendations?

A. Percutaneous revascularization +/- MCS

B. Surgical revascularization

C. Hybrid revascularization

D. LVAD/cardiac transplantation workup

E. Optimal medical therapy only

CTS Revascularization Evaluation

• Patient judged to be a very high risk

candidate for surgery.

– LAD does not appear to be a great target for

LIMA

• Referred for high risk PCI

PCI Revascularization Evaluation

• Patient will need revascularization with hemodynamic support

• Given the apical thrombus, this precludes the use of Impella device. He can be supported by TandemHeart device

• Initial procedure to address RCA, RAMUS, Left Circumflex, and CTO OM2.

• Staged procedure for CTO LAD/Diagonal

Mid rPAV into RPL2: overlapping DES x 3. Prox-distal RCA: overlapping

DES x 2

RAMUS: Single DES; Prox LCx to OM2: Overlapping DES x 3

LAD DES x 2; Diagonal PTCA only, LM-LCx DES bifurcation PCI

Conclusions

• Repeat echo in 3 months demonstrated

improved LV systolic function LVEF 40%

• Patient enrolled into cardiac rehab

• Patient quit smoking

Discussion

• Thoughts on mechanical circulatory

supported PCI?

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Thank you!

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