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

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

Dec 09, 2022 240 likes •480 views

Quelle assistance au cours de langioplastie avec signes de gravit ? Pr BONELLO Laurent Unit de soins intensifs de cardiologie Hop. Nord - Marseille Conflict of interest Lectures fee / honoraria Abiomed BTG Research

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SLIDE 1

Quelle assistance au cours de l’angioplastie avec signes de gravité ?

Pr BONELLO Laurent Unité de soins intensifs de cardiologie

  • Hop. Nord - Marseille
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SLIDE 2

Conflict of interest

  • Lectures fee / honoraria
  • Abiomed
  • BTG
  • Research grant:
  • Astrazeneca
  • Abbott
  • Boston
  • Biotronik
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SLIDE 3

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

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SLIDE 4

EMERGENT CATH

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SLIDE 5
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SLIDE 6

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

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SLIDE 7

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 …)

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SLIDE 8

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 7- Protected PCY with Impella CP 8- Protected PCI with ECMO 9- Medical therapy (Ischemia …)

Patient was turned down for surgery or ECMO

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SLIDE 9

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

  • r MCS

MCS Implan Implanta tatio tion n of

  • f a

an n Impe Impella lla CP CP with with go good

  • d ou
  • utp

tput ut (3,3 (3,3 l/m l/mn) n)

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SLIDE 10

LMT to LAD rotablator 1,5

100 mmHg

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SLIDE 11

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

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SLIDE 12

ST elevation after predilatation of the marginal

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SLIDE 13

Recurrent VT requiring Cardioversion

Followed by low pulsatility

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SLIDE 14

Finally successful PCI of the marginal

Dissection under the Cx stent

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SLIDE 15

At the end of the procedure

Low pulsatility despite NE and dobutamine

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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%
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SLIDE 17

Which mechanical support for high risk procedures ?

  • For Who ?
  • When ?
  • Which support ?
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SLIDE 18

En présence d’un choc cardiogénique:

Patients éligibles potentiel récupération /

candidat assistance LD / candidat à la greffe

For who ?

En l’absence de Choc cardiogénique

Risque intrinsèque / comorbidités 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

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SLIDE 19

When ?

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SLIDE 20

Which support?

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SLIDE 21

Proposed expert consensus algorithm

ECMO ECMO

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SLIDE 22

CONCLUSION

  • HD stabilization >> PPCI
  • Established algorithm
  • Shock team decision
  • Trained staff
  • Technical considerations, access,

indications of each device

TEAM TEAM WORK ORK