This case highlights Impella-supported complex revascularization in the setting of severe left ventricular dysfunction. The operators are Kate Kearney, MD, and William Lombardi, MD. Panelists are Tom Waggoner, DO, George Vetrovec, MD, and Seth Bilazarian, MD.

The patient is a 60-year-old male presenting with an NSTEMI 2 months prior to the procedure. Coronary angiography revealed a severe, calcified LAD/diagonal lesion and chronic total occlusion (CTO) of the circumflex/ramus and RCA. LVEF was 20%. The patient was deemed to not be a surgical candidate due to low EF, lack of lateral wall viability, and questionable distal RCA and circumflex targets. High-risk PCI was scheduled with Impella support due to low ejection fraction, complex coronary anatomy requiring atherectomy, and RCA CTO requiring a retrograde approach.

Dr. Lombardi describes the coronary anatomy and the plans for the case. Rotablator™ is passed through the LAD stenosis and preparation is made for delivering IVUS. Dr. Waggoner asks the team about having three access points—two femorals and a radial—and Dr. Kearney expresses her desire for an 8Fr guide for the CTO and rationale for not using the single access technique. “The single access works great,” she explains, “in STEMIs and a lot of those cases, but even the 7[Fr] can be a little bit difficult in terms of guide management. So, in these cases we sometimes just will forego that.”

Dr. Lombardi describes the importance of IVUS-guided PCI. “The data’s very clear that it reduces TVR, MI, and death,” he explains. “And so we always do IVUS-guided sizing so that we make sure we put in a properly sized stent.”

After successful LAD PCI, the operators proceed to the RCA CTO. Dr. Waggoner comments on the impact of complete revascularization for LV function recovery. Referring to some early data from the RESTORE EF trial that he’s a part of, he emphasizes, “I think it really shows that, you know, patients do better with complete revascularization.”

Dr. Lombardi describes planned steps for the CTO, starting with a retrograde approach. “There are cases that are just easier and faster to be done retrograde than antegrade, with, I think, equivalent safety.” He explains that these include cases with an occlusion length longer than 20 and calcium.

At follow-up one week later, Dr. Lombardi reports that the patient had an uneventful night and was discharged the following day. “Overall a good result with complete revascularization of the viable territories.”