Exceptional Challenges in PCI: Case Reviews Demonstrating Newest Techniques and Technologies

Sudden cardiovascular events are often preceded by embolus. The latest technologies for detection of emboli were showcased in a presentation by Emannouil S. Brilakis, MD, PhD, of the University of Texas, Southwestern Medical Center. Dr Brilakis presented “Intra-coronary Infrared Spectroscopy to Predict Embolization Risk During PCI.” This technology can be used to identify lesions before and even during the percutaneous coronary intervention (PCI) procedure. Lipid core plaques and lipid-core burden indices are easily measured without the need of computer image manipulation using this technology.

The problem with PCI is that with the creation of a new opening with new flow, you get reperfusion injury, which kills tissues. Previous examinations revealed that cooling can reduce infarction size for this damaging transition. Pete Fong, MD, of Vanderbilt University School of Medicine presented developments in rapid cooling of the heart using the Velomedix system. This involves threading with a trocar and controlled peritoneal lavage with a cold solution. Dr Fong is involved in the VELOCITY clinical trials, a multi-center RCT study involving 60 STEMI patients that will be treated by PCI. The treatment arm will also involve rapid Velomedix-mediated cooling to less than 35°C prior to PCI. Buspirone and meperidine were very important in their success to date. It is a simple procedure that does not involve any additional imaging. The data support that this rapid cooling system can decrease infarction size and improve revascularization after PCI.

Another presentation focused on preventing reperfusion injury. Howard A. Cohen, MD, Director of Interventional Cardiology of Temple University presented studies focused on ventricular unloading post-PCI. “Time is muscle in acute myocardial infarction, where decreasing door to balloon time is the mantra in PCI medicine, but perhaps we should focus more on function instead,” Dr Cohen stated. Maybe we should change our paradigm from “door to balloon” instead to ventricular unloading. The TandemHeart percutaneous left ventricular assistance device that Dr Cohen has been working on has now been shown to decrease infarct size post-PCI. It has been US Food and Drug Administration approved with anticipating enrollment in clinical trials.

The final talk by Dimitrios Karmpaliotis, MD, cardiologist at Athens University in Athens, Georgia discussed “Changing Chronic Total Occlusion and Fusion Imaging for the Planning and Guidance of Interventions.” Many videos presenting catheters entering anterograde and retrograde were presented, Dr Karmpaliotis emphasized the need for proper training and preparedness. A hybrid technique was presented along with data supporting that CTO revascularization is teachable. Unfortunately, Dr Karmpaliotis revealed that there are far too many errors when physicians are executing this relatively straightforward procedure. There appear to be too few doctors that are regularly practicing the technique. Dr Karmpaliotis pointed out that you should “always show your superior judgment so you don't have to show your superior skill.” He concluded that the technique is teachable and a physician should be able to proceed without concern if properly trained.

In summary, 2 successful technologies focused on preventing reperfusion post-PCI, while another described a hybrid PCI technique that can be used to promote revascularization. A technique for visualization of emboli during the PCI procedure was also presented. All were well received with apparent optimism.