how i deal with…and what to avoid… calcified disease adam de belder sussex cardiac centre...
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How I deal with…and How I deal with…and what to avoid…what to avoid…
calcified diseasecalcified diseaseAdam de BelderAdam de Belder
Sussex Cardiac CentreSussex Cardiac CentreBrightonBrighton
ACI 2009ACI 2009
Declaration of interestsDeclaration of interests
I have received honoraria from I have received honoraria from Boston Scientific to help train Boston Scientific to help train cardiologists in rotational cardiologists in rotational atherectomy.atherectomy.
Very narrowed/CTOVery narrowed/CTO
FibrousFibrous
FibrocalcificFibrocalcific
Superficial calciumSuperficial calcium
Deep calciumDeep calcium
Principle of RA operationPrinciple of RA operation
Differential CuttingDifferential Cutting AllAll diseased plaque is inelastic diseased plaque is inelastic High speed rotational ablation High speed rotational ablation
differentiates healthy elastic vessel wall differentiates healthy elastic vessel wall from plaquefrom plaque
High speed rotational ablation High speed rotational ablation preferentially cuts preferentially cuts allall types of plaque types of plaque morphologymorphology
Principle of OperationPrinciple of Operation
Differential CuttingDifferential Cutting
Elastic tissue is able to deflect out of the way
Elastic tissue space
Elastic tissuedeflects
Direction of motion
Diamond crystal
Inelastic tissue is unable to deflect out of the way
Inelastic tissue space
Direction of motion
Diamond crystal
Forcefulmechanicalbreakdownof matter
post-PTCA procedure post-Rotablator® procedure
Case Case
63 journalist - NSTEMI63 journalist - NSTEMI
Small balloon
bigger balloon
Even bigger balloon
Another case…..
4 balloons, the final one of which was a quantum at 26 atm
CRIKEY….!!
Non-obstructive dissection – rotablation?
4 weeks later…..
Final result
Calcification – what to avoidCalcification – what to avoid
Do not use oversized balloons in Do not use oversized balloons in native coronary arteries and inflate native coronary arteries and inflate them to very high atmospheres in them to very high atmospheres in order to ‘crack the lesion’…order to ‘crack the lesion’…
If a case needs to be treated by If a case needs to be treated by rotablation , decide at an early stage rotablation , decide at an early stage with conventional PCI and stop the with conventional PCI and stop the casecase
Calcification – what to avoidCalcification – what to avoid
Inexperienced users have the highest Inexperienced users have the highest complication rates - do not use rotablation complication rates - do not use rotablation occasionally – buddy up with an occasionally – buddy up with an experienced colleague or pass the case on experienced colleague or pass the case on to a regular user of the technologyto a regular user of the technology
……sometimes, you have to swallow your sometimes, you have to swallow your pride and accept that there are some pride and accept that there are some cases that balloons and stents can’t treatcases that balloons and stents can’t treat
Rotablation experience – Sussex Rotablation experience – Sussex Cardiac CentreCardiac Centre
N =222N =222 70% >70yrs, 25%>80yrs70% >70yrs, 25%>80yrs Hypertension – 84%Hypertension – 84% Failure to cross or poor result – 6.7%Failure to cross or poor result – 6.7% Successful result – 93.3%Successful result – 93.3% Complications – death n=2, QWMI Complications – death n=2, QWMI
n=1, dissection n=4, perforation n=1, dissection n=4, perforation n=3, tamponade n=1n=3, tamponade n=1
Case – understanding calciumCase – understanding calcium
55 yrs55 yrs Stable anginaStable angina Prox LADProx LAD Previous pci severe dog-boningPrevious pci severe dog-boning
Once you are confident with what can be Once you are confident with what can be achieved with RA, higher risk cases can be achieved with RA, higher risk cases can be
undertakenundertaken 87 yrs87 yrs Hb 9Hb 9 Creat 400Creat 400 Too high risk for surgeryToo high risk for surgery Intractable anginaIntractable angina
ConclusionsConclusions Understand the nature of the heavily calcified Understand the nature of the heavily calcified
coronary arterycoronary artery Understand the limitations and potential harm Understand the limitations and potential harm
POBA and stenting can doPOBA and stenting can do Do some IVUS and see what you’re dealing withDo some IVUS and see what you’re dealing with Learn/refresh how to rotablate with a proctorLearn/refresh how to rotablate with a proctor Rotablation is not without risk – understand Rotablation is not without risk – understand
potential complications and how to avoid thempotential complications and how to avoid them Frequent users have better results and are more Frequent users have better results and are more
confident with its capabilityconfident with its capability If you think the case requires a rotablation If you think the case requires a rotablation
facility, then it probably does..facility, then it probably does.. ..perhaps the laser?..perhaps the laser?
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