Approach to the high risk PCI

patient

Ted Feldman, M.D., FSCAI FACC FESC

Evanston Hospital

SCAI Annual Fellows Course

Las Vegas
December 5th-8th, 2012
 Ted Feldman MD, FACC, FESC, FSCAI

Disclosure Information
The following relationships exist:

Grant support: Abbott, BSC,

Edwards, St Jude, WL Gore
Consultant: Abbott, BSC, Coherex, Edwards, Intervalve,
Diiachi Sankyo-Lilly, WL Gore
Speaker: Boston Scientific

Off label use of products and investigational devices

will be discussed in this presentation
 Risk Factors for PTCA Hospital Death
NY State Database 1991-94
20
Odds Ratio for Death

18 18.31
16
14
12
10
8
6 4.15 3.68
3.51
4 5.22
2.38 2.39
3.67 1.49 1.82 1.78 1.43 1.41 1.31
2 1.06 0.59
2.1
0

When tested in a stent era population of 4063 procedures Holmes et al

this model predicted both hospital & long term outcome Circ 102:517,2000
 Poor LV Function

Remaining coronary circulation

LVEDP 36 mmHg
Remaining coronary circulation POST PCI

PRE Post IV NTG Post PCI Post Lasix

LVEDP = 36 mmHg LVEDP= 16 mmHg LVEDP=31 mmHg LVEDP=22 mmHg
chest pain

Poor LV Function
 Assessing PCI Risk
1
0.9
0.8
PCI Anatomy

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Patient Complexity
 Assessing PCI Risk
1
0.9
0.8
High Risk Anatomy High Risk Anatomy
PCI Anatomy

0.7
0.6 Low Risk Patient High Risk Patient
0.5
0.4
0.3 Low Risk Anatomy
0.2 High Risk Patient
0.1
0
Patient Complexity
 Assessing PCI Risk
1
0.9
0.8
PCI Anatomy

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0

Patient Complexity
 Assessing PCI Risk
1
0.9
0.8
SYNTAX Score

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0

EuroScore/ STS Risk

  Talk to your patient before, during, & after
catheterization
Avoiding & • read the chart

Managing  Plan the case

Complications • equipment
• environment
• support
 Call a failure a failure
• Learn how to say I’m sorry
Technical
 Ask for help
Cognitive  No other option is not an indication to do a
procedure
 Optimal Femoral artery access
 Pericardiocentesis
 Do not treat nonischemic symptoms
Philosophical
 Prevention of contrast nephropathy & bleeding

Preventing complications of diagnostic cardiac catheterization: some cognitive and philosophical issues, and a couple of critical techniques.
In Complications in Percutaneous Interventions for Congenital and Structural Heart Disease, pages 321-336, 346-352, Informa, London, 2009.
Failure is a dress rehearsal for success.