Vol 30, No 1 (2023)
Image in Cardiovascular Medicine
Published online: 2023-02-27

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interventionAL CARDIOLOGY


Cardiology Journal

2023, Vol. 30, No. 1, 159–160

DOI: 10.5603/CJ.2023.0011

Copyright © 2023 Via Medica

ISSN 1897–5593

eISSN 1898–018X

Impella-rota-shock percutaneous coronary intervention: Three weapons, one last remaining vessel

Alexandra BriosaAna Rita PereiraMariana MartinhoRita CaléHélder Pereira
Cardiologia Department, Hospital Garcia de Orta EPE, Almada Portugal

Address for correspondence: Alexandra Briosa, MD, Cardiologia Department, Hospital Garcia de Orta, EPE,
Av. Prof. Torrado da Silva, 2801-951 Almada, Portugal, tel: +351 212727168, e-mail: alexandrabriosaneves@gmail.com

Received: 1.08.2022 Accepted: 9.12.2022

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

A 59-year-old man was admitted with decompensated heart failure. Transthoracic echocardiogram revealed left ventricular ejection fraction (LVEF) of 22% and severe secondary mitral regurgitation. Coronary angiography showed 80%/95% stenosis on the proximal/mid segments of left anterior descendant (LAD) and chronic total occlusions (CTO) in circumflex (CXA) and right coronary (RCA) arteries. Cardiac scintigraphy confirmed myocardial viability. He was refused for myocardial revascularization surgery due to high surgical risk (EuroScore II: 6.8%, SYNTAX: 30). LAD percutaneous coronary intervention (PCI) was performed under short-term mechanical support with Impella CP® with SmartAssist SystemTM. Contrast enhanced computed tomography was performed to assess vasculature. A dual femoral access was obtained: 14 and 8 French sheaths for device insertion and PCI, respectively. Throughout the procedure, the patient’s cardiac output was supported by the device. A rotational atherectomy was performed with a 1.25 mm bum followed by balloon dilatation (semi-compliant balloons 1.0 × 8 mm/2.0 × 15 mm, and noncompliant balloons 2.0 × 20 mm/2.5 × 30 mm). Further lesion preparation was needed, using lithotripsy balloon 2.5 × 12 mm (SHOCKWAVE Medical) and a super high-pressure balloon (2.5 × × 20 mm), followed by pharmacological stent implantation (2.50 × 20 mm and 2.75 × 33 mm in mid/proximal LAD), with good result (Fig. 1, Suppl. Video 1). The access site was closed with Proglide percloseTM technique and AngiosealTM closure device. One year later, he was submitted to RCA and CXA CTO PCI, with significant improvement of LVEF (38%).

Figure 1. Coronary angiography images before percutaneous coronary intervention (PCI) showing: A. An 80% and 95% stenosis on the proximal and mid segment of left anterior descendant (LAD); B. A chronic occlusion of the right coronary artery; C. PCI of LAD under short-term mechanical support with Impella deviceTM, starting with rotational atherectomy with a 1.25 mm bum; D. Further lesion preparation with intravascular lithotripsy; E. Drug-eluting stent implantation; F. Final result.

This case highlights the importance of “Rota--Shock-Impella” strategy in patients who were refused surgery due to a high-risk profile. Although this strategy may be safe and life-changing, further studies are needed to prove the long-term benefit of this strategy.

Conflict of interest: None declared