Questions / Answers from November 16, 2010 Case
Questions / Answers
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Besides the contraindications of poor vascular access, LV thrombus and aortic valve disease, are there any special factors to be cautious about when placing an Impella in the elderly? |
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These are the usual factors to be considered before Impella placement, which becomes even more important in the elderly especially Iliac and aortic tortuousity. |
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Are you using the micro catheter for gaining access in every PCI? |
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YES almost in all cases and this technique has further reduced our vascular complications especially when large bore sheaths are used (10-13Fr. |
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What is your removal strategy for Impella - pre-close every time? |
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YES Preclose using 2 sutures all the time. This strategy with bivalirudin as anticoagulant has almost eliminated any vascular complications even with these 12-13Fr sheath |
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In what situations will you not remove the Impella in the CVL? |
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The cases of cardiogenic shock may continue to Impella device left in place for 1-5 additional days in the CCU. We need to keep ACT >300sec or aPTT >90sec in these pts by Q4-6hrs check. This is a must to avoid any clot formation on the device. |
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If the platelet study shows a platelet inhibition less than 30% on Clopidogrel 75 mg, and there are no contraindications for Prasugrel, would you double the dose of Clopidogrel or switch to Prasugrel? |
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In this situation, based on the published data, my recommendation will be to switch to Prasugrel (30mg load and 5-10mg maintainenece daily). Yes many of these pt's can get to >40% platelet inhibition by doubling the clopidogrel dose, but about 15% still will be poor responders. We also know that Prasugrel will take care of this unresponsiveness in over 98% of cases. |
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In what situations are you not using Bivalirudin? |
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We are using Bivalirudin in all PCI cases (including CTOs) and all PTA cases except PTA-CTOs. Also in the Protect II trial we have to use heparin so also will be case in TAVI trial of the Medtronic Core Valve. |
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Where do you see the role of the Lipiscan? In what cases? How would it compare to IVUS Virtual Histology? |
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I consider Lipiscan as the research tool at present to understand the mechanism of complications of PCI such as no-reflow and embolization. It is a great tool for evaluation and identification of vulnerable plaque, in which it will play better then IVUS virtual histology. It's impact in clinical practice is still evolving, largely hampered by no reimbursement for the Lipiscan technique yet. |
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In what situations do you feel are platelet aggregation studies mandatory? |
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Pts who are high risk such as Diabetic, obese, multiple (>3) stents and where stent thrombosis could be catastrophic (PCI of Left main, proximal LAD, complex bifurcation or single vessel supplying the heart). |
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What is the best renal protection strategy for this patient? |
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Still gentle po/IV hydration pre- and post, N-acetylcystein 1200mg pre and 2 doses |
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We heard you mention continuation of Bivalirudin for 1 hour post PCI. Some reports suggest 2 hours. Can you clarify? |
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When clopidogrel is given on the table, it takes about 120-150 minutes to achieve the peak platelet inhibitory effect. Bivalirudin with half life of 25 minutes, if stopped at the end of the PCI, will predispose pts for early stent thrombosis in 75-150 minutes time frame. Hence in these pts continuation of Bivalirudin infusion for 1-2 hrs is advised to eliminate this early risk. We continue infusion for 1 hour but some do continue upto 2-3hrs. Also this strategy has not resulted in increased vascular bleeding. |
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What is the benefit of the information provided by the new device versus the IVUS? |
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Lipiscan is more specific for detection of vulnerable plaque and lipid contents of the lesion. IVUS resolution will be not be great for these detections. |
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8 years ago I had undergone an angiography before my MV REPLACEMENT. I didn't have any vascular problem, but I am worry now because my hypertensive problem, AF problems... I am 65 years old. There is another possibility to check with out angiography? |
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Yes. 64-slice coronary CTA will be a reasonable alternate to avoid invasive angiography. If CTA reveals blockage then, coronary angiography with stent (or even CABG if extensive disease) will be the next natural step. |
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In patient with cardiogenic shock due to STEMI. Do you have any tips on how to select good candidates for survival? |
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This is the field in Interventional Cardiology, where despite all the newer advances including LV assist devices, had not made any dent in the 30-day survival of 30-35%. On personal note, young pts (<75yrs age) without extensive co-morbid conditions and PCI done in 16-24hrs of shock, may be the good candidate for Cardiogenic Shock survival. |
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