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CASE REPORT CLINICAL CASE A Case of Rota-Shock-Pella Ka Chun Alan Chan, MBBS, Ngai Hong Vincent Luk, MBBS, Kang Yin Michael Lee, MBBS, Kam Tim Chan, MBBS ABSTRACT Severe calcied coronary lesions are frequently encountered in todays percutaneous coronary intervention practice and remain a challenging entity in complex and high-risk patients. The present case illustrates the contemporary approach to management of this coronary problem from hemodynamic support, optical coherence tomography assessment, and plaque modication technique. (Level of Difculty: Advanced.) (J Am Coll Cardiol Case Rep 2019;1:76570) © 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PRESENTATION A 74-year-old gentleman presented to the emergency department for acute decompensated heart failure. He had 2-week history of progressive exertional dys- pnea and lower limb edema before admission. He did not have angina, palpitation, or syncope. MEDICAL HISTORY The patient had history of hypertension, hyperlipid- emia, and diabetes mellitus. He was a nonsmoker. INVESTIGATION Laboratory tests showed normal renal function and troponin level. Electrocardiogram showed sinus tachycardia whereas chest radiography revealed car- diomegaly and congested lung eld. Echocardiogra- phy showed globally impaired left ventricular ejection fraction of 25% to 30% and with multiple regional wall motion abnormalities. There was only mild mitral regurgitation. Coronary angiography (Figure 1, Videos 1 and 2) performed as part of the ischemic workup showed a nondominant LCX and diffuse severe calcication along the left main, LAD, and RCA. There was severe stenosis in the distal left main, proximal LAD and proximal RCA. Mid LAD and mid RCA were totally occluded. Nuclear stress imag- ing showed multiple regions of ischemia without infarct. MANAGEMENT The patient was stabilized with anti-heart failure medication. The case was discussed among the heart team, but bypass surgery posed too high risk and was turned down as the distal targets were poor. High-risk percutaneous coronary intervention (PCI) LEARNING OBJECTIVES To understand the limitation of angiograms and the usefulness of optical coherence to- mography in the assessment of coronary calci cation. To understand the latest contemporary approach of interventional treatment of se- vere coronary calci ed disease. To be familiar with the latest technology for treating calci ed coronary disease by using Shockwave lithotripsy. ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2019.10.028 From the Department of Medicine, Queen Elizabeth Hospital, Hong Kong, China. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. John W. Hirshfeld, Jr., MD, served as Guest Associate Editor for this paper. Informed consent was obtained for this case. Manuscript received September 23, 2019; revised manuscript received October 29, 2019, accepted October 31, 2019. JACC: CASE REPORTS VOL. 1, NO. 5, 2019 ª 2019 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).

A Case of Rota-Shock-Pella · A Case of Rota-Shock-Pella DECEMBER 18, 2019:765– 70 766. branch and the small LCX artery, further lesion preparation was performed by using a Shockwave

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Page 1: A Case of Rota-Shock-Pella · A Case of Rota-Shock-Pella DECEMBER 18, 2019:765– 70 766. branch and the small LCX artery, further lesion preparation was performed by using a Shockwave

J A C C : C A S E R E P O R T S V O L . 1 , N O . 5 , 2 0 1 9

ª 2 0 1 9 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A N

C O L L E G E O F C A R D I O L O G Y F OU N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R

T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .

CASE REPORT

CLINICAL CASE

A Case of Rota-Shock-Pella

Ka Chun Alan Chan, MBBS, Ngai Hong Vincent Luk, MBBS, Kang Yin Michael Lee, MBBS,Kam Tim Chan, MBBS

ABSTRACT

L

ISS

Fro

rel

pa

Inf

Ma

Severe calcified coronary lesions are frequently encountered in today’s percutaneous coronary intervention practice and

remain a challenging entity in complex and high-risk patients. The present case illustrates the contemporary approach to

management of this coronary problem from hemodynamic support, optical coherence tomography assessment,

and plaque modification technique. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2019;1:765–70)

© 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

PRESENTATION

A 74-year-old gentleman presented to the emergencydepartment for acute decompensated heart failure.He had 2-week history of progressive exertional dys-pnea and lower limb edema before admission. He didnot have angina, palpitation, or syncope.

MEDICAL HISTORY

The patient had history of hypertension, hyperlipid-emia, and diabetes mellitus. He was a nonsmoker.

EARNING OBJECTIVES

To understand the limitation of angiogramsand the usefulness of optical coherence to-mography in the assessment of coronarycalcification.To understand the latest contemporaryapproach of interventional treatment of se-vere coronary calcified disease.To be familiar with the latest technology fortreating calcified coronary disease by usingShockwave lithotripsy.

N 2666-0849

m the Department of Medicine, Queen Elizabeth Hospital, Hong Kong, C

ationships relevant to the contents of this paper to disclose. John W. Hirshf

per.

ormed consent was obtained for this case.

nuscript received September 23, 2019; revised manuscript received Octob

INVESTIGATION

Laboratory tests showed normal renal function andtroponin level. Electrocardiogram showed sinustachycardia whereas chest radiography revealed car-diomegaly and congested lung field. Echocardiogra-phy showed globally impaired left ventricularejection fraction of 25% to 30% and with multipleregional wall motion abnormalities. There was onlymild mitral regurgitation. Coronary angiography(Figure 1, Videos 1 and 2) performed as part of theischemic workup showed a nondominant LCX anddiffuse severe calcification along the left main, LAD,and RCA. There was severe stenosis in the distal leftmain, proximal LAD and proximal RCA. Mid LAD andmid RCA were totally occluded. Nuclear stress imag-ing showed multiple regions of ischemia withoutinfarct.

MANAGEMENT

The patient was stabilized with anti-heart failuremedication. The case was discussed among the heartteam, but bypass surgery posed too high risk andwas turned down as the distal targets were poor.High-risk percutaneous coronary intervention (PCI)

https://doi.org/10.1016/j.jaccas.2019.10.028

hina. The authors have reported that they have no

eld, Jr., MD, served as Guest Associate Editor for this

er 29, 2019, accepted October 31, 2019.

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FIGUR

See Vi

ABBR EV I A T I ON S

AND ACRONYMS

CTO = chronic total occlusion

LAD = left anterior descending

artery

LCX = left circumflex artery

OCT = optical coherence

tomography

PCI = percutaneous coronary

intervention

RCA = right coronary artery

Chan et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 5 , 2 0 1 9

A Case of Rota-Shock-Pella D E C E M B E R 1 8 , 2 0 1 9 : 7 6 5 – 7 0

766

with Impella (Abiomed, Danvers, Massa-chusetts) support to the left main/LADchronic total occlusion (CTO) was performedat first stage and PCI to RCA CTO wasplanned in a staged procedure for completerevascularization. A hemodynamically sup-ported device was used for the first pro-cedure in view of poor left heart function, asingle surviving vessel, and anticipatedatherectomy for severe calcification. Afterusing the crossover technique for left com-mon femoral access and pre-close with 1

Proglide suture (Abbott Vascular Devices, Temecula,California), an Impella CP was implanted, and an 8-Fextra back up 3.5 guide (Medtronic, Minneapolis,Minnesota) from the right femoral was used toengage the left main (Video 3). Mid calcified LAD

E 1 Baseline Angiogram

deos 1 and 2.

CTO lesion was crossed using the Fielder XT-R(Asahi Intec, Nagoya, Japan) supported by theTurnpike Spiral microcatheter (Vascular Solutions,Minneapolis, Minnesota). The CTO segment wascrossed by the microcatheter with difficulty becauseof severe calcification, and an initial atherectomywas planned. Rotablation using a 1.5 mm (BostonScientific, Natick, Massachusetts) was used, and amultiple brief pecking motion was performed at160,000 rpm (Figure 2). There was brief stunning ofthe myocardium during rotablation, which was fullysupported by the Impella CP. Thrombolysis inmyocardial infarction 3 flow was established, andoptical coherence tomography (OCT) was performed.There was a thick (>0.5 mm), long (>5 mm), andcircumferential calcification along the whole LAD(Figure 3, Video 4). After wiring the big diagonal

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FIGURE 2 Interventional Setup and Details

See Video 3.

J A C C : C A S E R E P O R T S , V O L . 1 , N O . 5 , 2 0 1 9 Chan et al.D E C E M B E R 1 8 , 2 0 1 9 : 7 6 5 – 7 0 A Case of Rota-Shock-Pella

767

branch and the small LCX artery, further lesionpreparation was performed by using a Shockwavelithotripsy balloon (Shockwave Medical, Fremont,California). A 2.5-mm Shockwave balloon was infla-ted to 4 atm, and therapy was given along the midLAD segment in 8 cycles of 10 pulses each, while a 3-mm Shockwave balloon was used to treat the distalleft main and proximal LAD in a similar fashion.Post-Shockwave OCT showed deep fracture of thecalcified plaque along the LAD and with satisfactoryluminal gain (Figure 4, Video 5). Left main to distalLAD were stented with long overlapping Xience Si-erra stents (3.5 mm, 3.0 mm, 2.5 mm, and 2.25 mm;Abbott Vascular). After adequate post-dilation, fin-ishing angiogram and OCT showed satisfactory resultwith good stent expansion and apposition (Figure 5,Videos 6, 7, and 8). The Impella CP was removed, and

left femoral access was closed with original Proglide(Abbott Vascular) sutures and 1 additional 8-F Angio-seal (Terumo, Somerset, New Jersey).

DISCUSSION

Patients with severe calcified coronary lesions pose atherapeutic challenge to interventional procedure.Coronary calcification is frequently underestimatedby angiography alone (1). Intracoronary imaging inparticular OCT has a higher sensitivity in detectingcoronary calcification (2). OCT allows quantitativeassessment of the degree of calcification bymeasuring the thickness, arc, length, and volume.Such diagnostic accuracy enables a better under-standing of the calcified plaque morphology beforecontemplating PCI. Fujino et al. (3) showed that OCT-

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FIGURE 3 Post-Rotablation OCT

See Video 4. OCT ¼ optical coherence tomography.

FIGURE 4 Shockwave Lithotripsy and Post-Therapy OCT

See Video 5. OCT ¼ optical coherence tomography.

Chan et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 5 , 2 0 1 9

A Case of Rota-Shock-Pella D E C E M B E R 1 8 , 2 0 1 9 : 7 6 5 – 7 0

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FIGURE 5 Final Angiogram and Optical Computed Tomography

See Videos 6, 7, and 8.

J A C C : C A S E R E P O R T S , V O L . 1 , N O . 5 , 2 0 1 9 Chan et al.D E C E M B E R 1 8 , 2 0 1 9 : 7 6 5 – 7 0 A Case of Rota-Shock-Pella

769

derived calcium scoring (in term of calcium thickness,length, and arc of involvement) could predict stentunderexpansion and provided a framework for usingan upfront plaque modification technique. Contem-porary rotational atherectomy techniques, includingchoice of burr size, rotational speed, short run ofpecking motion, and final polishing run, were welldescribed in both European and U.S. professionalsocieties (4,5). The latest paper by De Maria et al. (6)provided a comprehensive review of the latesttechnology and treatment algorithm for tacklingcalcified coronary lesions. Initial atherectomy wasrecommended for severe calcified disease that couldnot be crossed by a balloon. OCT could assess theresidual calcium plaque burden, as in the presentcase. Further balloon pre-dilation would usually be

required to break or fracture the calcium before stentimplantation. It was conventionally achieved bymeans of a high-pressure noncompliant balloon or bycutting or scoring balloon. It was not without risk ofperforation, and it was associated with a high risk ofhemodynamic compromise in such vulnerable, com-plex, and high-risk patients. It was shown in bothclinical (7) and OCT studies (8) that satisfactory lesionpreparation and calcium fracturing could be achievedby using Shockwave lithotripsy balloon. It onlyrequired a low inflation pressure and had minimalrisk of coronary perforation. Because of the profile ofthe current Shockwave balloon, it would not crossthose tight calcified lesions before rotablation andhence “Rota-shock” may become a very attractiveapproach in such scenario. Very satisfactory calcium

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fracturing and acute luminal gain can finally be ach-ieved after Shockwave lithotripsy followed by excel-lent stenting result.

FOLLOW-UP. Follow-up echocardiography showedimproved left ventricular ejection fraction of 45% to50%. Successful PCI to RCA CTO using an antegradeapproach was performed 3 months later. The patientwas recently seen in the authors’ heart failure clinicand remained in New York Heart Association func-tional class I/II symptoms.

CONCLUSIONS

Severe calcified coronary lesion in complex and high-risk patients can be safely treated with an approachcombining Rota-Shock-Pella.

ADDRESS FOR CORRESPONDENCE: Dr. Ka Chun AlanChan, Department of Medicine, Queen ElizabethHospital, Hong Kong, China. E-mail: [email protected].

RE F E RENCE S

1. Mintz GS, Painter JA, Pichard AD, et al.Atherosclerosis in angiographically “normal” cor-onary artery reference segments: an intravascularultrasound study with clinical correlations. J AmColl Cardiol 1995;25:1479–85.

2. Wang X, Matsumura M, Mintz GS, et al.In vivo calcium detection by comparing opticalcoherence tomography, intravascular ultrasound,and angiography. J Am Coll Cardiol Img 2017;10:869–79.

3. Fujino A, Mintz GS, Matsumura M, et al.A new optical coherence tomography-basedcalcium scoring system to predict stent under-expansion. EuroIntervention 2018;13:e2182–9.

4. Emanuele Barbato, Didier Carrié, Petros Dar-das, et al. European expert consensus on rota-tional atherectomy. EuroIntervention 2015;11:30–6.

5. Sharma SK, Tomey MI, Teirstein PS, et al. NorthAmerican expert review of rotational atherectomy.Circ Cardiovasc Interv 2019;12:e007448.

6. De Maria GL, Scarsini R, Banning AP, et al.Management of calcific coronary artery lesions: isit time to change our interventional therapeuticapproach? J Am Coll Cardiol Intv 2019;12:1465–78.

7. Brinton TJ, Ali ZA, Hill JM, et al. Feasibility ofShockwave coronary intravascular lithotripsy for

the treatment of calcified coronary stenoses. Cir-culation 2019;139:834–6.

8. Ziad A. Ali, Todd J. Brinton, Jonathan M. Hill,et al. Optical coherence tomography character-ization of coronary lithoplasty for treatment ofcalcified lesions. J Am Coll Cardiol Img 2017;10:897–906.

KEY WORDS Impella, OCT, PCI, rotationalatherectomy, Shockwave lithotripsy

APPENDIX For supplemental videos,please see the online version of this paper.