Quelle assistance au cours de langioplastie avec signes de gravit ? - PowerPoint PPT Presentation

Quelle assistance au cours de l’angioplastie avec signes de gravité ? Pr BONELLO Laurent Unité de soins intensifs de cardiologie Hop. Nord - Marseille

Conflict of interest • Lectures fee / honoraria • Abiomed • BTG • Research grant: • Astrazeneca • Abbott • Boston • Biotronik

Case • Mr L. 58 y.o, hypertension -NSTEMI with recurrent chest pain • Aspirin, UFH • ECG • TTE: LVEF 35%, no valvular disease, preserved RV function and CI

EMERGENT CATH

Severe distal LMT Severe ostial LMT Severe proximal LAD Severe first Mg Occluded distal CX Severe distal LAD

What to do ? 1- Call a friend 2- Wait for a webinar or live case 3- Call a surgeon to operate 4- Ad-Hoc PCI by an expert operator (CHIP) 5- Ad-Hoc PCI with drugs and support device in case of HD instability 5- Protected PCI with IABP 6- Protected PCI with Impella 2,5 7- Protected PCY with Impella CP 8- Protected PCI with 9- Medical therapy (Ischemia …)

What I recommend 1- Call a friend 2- Wait for a webinar or live case 3- Call a surgeon to operate 4- Ad-Hoc PCI by an expert operator (CHIP) 5- Ad-Hoc PCI with drugs and support device in case of HD instability 5- Protected PCI with IABP 6- Protected PCI with Impella 2,5 Patient was turned 7- Protected PCY with Impella CP down for surgery or 8- Protected PCI with ECMO ECMO 9- Medical therapy (Ischemia …)

Our plan 1- save the LAD 2- secondly the Circ • 2 operators/ 1 ICU and 1 CCU care physicians • Central venous line ready for Norepinephrine and dobutamine • HNF checked for ACT >250 s • Aspirin and ticagrelor 180 mg Nee Need for or MCS MCS Implan Implanta tatio tion n of of a an n Impe Impella lla CP CP with with go good od ou outp tput ut (3,3 (3,3 l/m l/mn) n)

LMT to LAD rotablator 1,5 100 mmHg

PCI of LAD and LMT, pot and kissing LAD / CX … (1 stent lost in the LMT)

ST elevation after predilatation of the marginal

Recurrent VT requiring Cardioversion Followed by low pulsatility

Finally successful PCI of the marginal Dissection under the Cx stent

At the end of the procedure Low pulsatility despite NE and dobutamine

Early course • Transfer to ICU under support LVEF 10-15% not intubated • After 12 hours of unstability, LVEF increases and the patient is weaned for drugs and Impella during the following 24 hours Follow-up at 3 months • Alive • LVEF 60%

Which mechanical support for high risk procedures ? • For Who ? • When ? • Which support ?

For who ? En l’absence de Choc cardiogénique En présence d’un choc cardiogénique: Risque intrinsèque / comorbidités Patients éligibles potentiel récupération / candidat assistance LD / candidat à la greffe Risque anatomique Large zone à risque Dernier vaisseau Risque technique Syntax score élevé Artériectomie directionnelle Inflations prolongées Angioplasties multiples Leurent G. cardio et angio 2018

When ?

Which support?

Proposed expert consensus algorithm ECMO ECMO

CONCLUSION • HD stabilization >> PPCI • Established algorithm • Shock team decision • Trained staff • Technical considerations, access, indications of each device TEAM TEAM WORK ORK