Cath Lab Digest

Introduction

The advent of left ventricular assist devices has allowed the interventional cardiology community to perform complex coronary interventional procedures in a safe, effective manner.  Initial iterations of left ventricular assist devices demanded a modest amount of technical abilities, and therefore adoption of this technology was not very widespread.  The advent of the Impella 2.5 circulatory support device (Abiomed, Inc., Danvers, Mass.) has enabled interventional cardiologists to perform more complex coronary interventions.¹   

Recently, the PROTECT II trial demonstrated that revascularization of these complex patients is appropriate and improves their NYHA classification. Fifty-eight percent of patients in class III/IV were able to move their classification of heart failure down by one or more levels, thus improving their quality of life. The PROTECT II trial data, presented at the TCT 2011 conference in San Francisco, also demonstrated that more complete revascularization with Impella 2.5 leads to better outcomes, with a 34% reduction in major adverse events (MAE) over the intra-aortic balloon pump (IABP) arm. When PCI was performed in patients supported by Impella 2.5 and extensive revascularization was done, major adverse cardiac and cerebral events (MACCE) rates were 47% lower than the patients supported by an IABP.² It is believed that the reduction in MAE is due to the ability of the interventional cardiologists to perform more thorough revascularization with the support provided by the Impella device.  

Traditionally, a high risk percutaneous coronary intervention (PCI) is considered to be an intervention in which a patient has either left main disease or multivessel disease, suppressed LV ejection fraction, or a combination of the two. Recent data suggests that individuals with normal LV function who have lesions in coronary anatomy that place large territories of myocardium in jeopardy are also considered high risk.³ This case demonstrates such a scenario.

Case

This patient is a 77-year-old male with a history of ulcerative colitis, severe chronic obstructive pulmonary disease (COPD), bladder cancer, and surgically removed pheochromocytoma, who presented to the hospital with angina and progressive dyspnea.  Stress testing revealed a very large, reversible inferolateral defect. Cardiac catheterization revealed a high-grade stenosis in the ostium of a dominant circumflex (Cx) coronary artery and a left ventricular ejection fraction (LVEF) of about 45%. Because of the location of the lesion, medical therapy was recommended. Post procedurally, the patient developed an acute embolic thalamic stroke. He recovered from his stroke and within a few weeks was admitted to the hospital again with identical symptoms, while on optimal medical therapy. Given his recent stroke and significant COPD, surgical revascularization was declined.   

In order to adequately cover the ostium of his Cx, we had to ensure that a small portion of the deployed stent would have to protrude into the distal left main. To properly position the stent, and to avoid plaque shifting into the left main and the left anterior descending (LAD) coronary artery, we chose to employ a modification of the balloon backstop technique described in the past.⁴ Dual balloon inflation with one balloon inflated from left main into the LAD and the treating balloon inflated in the ostial Cx would create a large area of global ischemia, especially given the left dominant nature of the patient’s coronary anatomy. In order to effectively position both balloons without having to hastily perform the procedure, we chose to support the intervention with the Impella 2.5 circulatory support device.