Questions / Answers from January 19, 2010 Case

Questions / Answers

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Is this the type of patient that would have been a good candidate for thePROTECT II impella vs IABP high risk PCI trial?  Is this a trial you participate in?
YES We participate in PROTECT II trial and are second lead enroller in the country. Also this patient will qualify to be in the PROTECT II trial.
What are the advantages and disadvantages of Perclose?
Two perclose as Preclose have worked very well and have reduced the vascular complications and hematoma post-procedure. Disadvantage besides unfavorable anatomy is that it adds upto 10 minutes to the total patient preparation.
I notice that nursing staff where hair protection and masks while the operators use only hair protection  and no masks and Dr. Sharma who uses neither. Can you tell me if there is any concern over infection control during PCI cases?
Yes cap and masks are routinely used by our cath lab staff. During live relay, mask may hamper voice clarity and hence could be excused. Overall infection rate in our cath lab for last few years has been 0%. Society of coronary angiography and intervention recommend but DONOT MANDATE the routine use of cap and masks.
What is the recommended anticoagulant and antiplatelet therapy for the Impella device?
IV heparin boluses to keep ACT between 300-350sec. We now have started doing these Impella cases on Bivalirudin again to keep ACT >300sec, largely due to it's ability to decrease vascular/bleeding complications.
Are you using only the LVEF as the criteria to choose between IABP and Impella?
Actually both LV function and lesion complexity enter in the decision making. Complex lesions with LVEF <20% will get Impella and >35% will get IABP. In 20-35% range, choice depends on coronary anatomy and overall hemodynamic of the pts. Pts with borderline hemodynamic and complex lesions usually gets Impella.
Where will you not use the Impella device?
Pts with aortic valve disease and LV thrombus besides having PVD.
Is the Impella device being used by your cardiac surgeons?
Not yet Soon they will be evaluating Impella 5.0.
The Quick set up has obvious advantages for STEMI patients?  Can you comment on those?
YES as it will shorten the prep time by 15 minutes in these acute situations.
How much has the Impella device affected your use of the Tandem Heart and IABP?
It has not much affected IABP as only 1-2 Impella are being used per month and IABP volume is 40/month. Yes TandemHeart PTVA has disappeared from cath lab for PCI support (none in 2009). We still use Tandem Heart in cases of cardiomyopathy as bridge to transplant.
Where do you see the trend amongst Impella, Tandem Heart and IABP?
All depends on the results of PROTECT II trial; if +in favor of Impella then almost 50% of IABP volume could shift towards Impella.
How much time are you actually saving between the old set up and the Impella Quick Set up?
Solid 15 minutes.
Have you had an opportunity to use the Impella device for STEMI at your institution?  Where can one learn more about it?
One case so far in STEMI with the old setup. Still waiting for an appropriate STEMI with the quick setup.
What about the use of IVUS in this case?  Is your overall use of IVUS up or down?  
Overall IVUS use is up in USA as well as in our cath lab. In 2006-12%, 2007-14% and 2008 and 2009-20%. In this particular ULM case, if there is no question of stent expansion or dissection on angiogram, IVUS will not be used routinely. That is our routine practice although can be questioned by many. I am actually talking about 'lack of data on routine IVUS use during PCI' in one of the ACCi2 session this year.
What stent will you use here and why?
XienceV by virtue of its ease of delivery and low stent thrombosis rate, will be the preferred stent. Also pt can off the plavix after one year Xience V use
Is this is good case to use the Cypher?
Yes This lesion will be good for Cypher also and infect that what we have been using before XienceV DES with restenosis rate of <5%.
What will be your duration of anti-platelet therapy in this case and will you bring the patient back for a surveillance angiography?
After XienceV DES if no restenosis, then Plavix  for 12 months and then taper it by making every other day for one month and then stop.
Where do you remove the Impella device?
All cases in the cath lab after the procedure. If pt still need some hemodynamic support, then insert IABP for 24-48hrs.

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