New Advances in the Treatment of Severe Coronary Artery Calcifications.

Coronary artery calcifications are always challenging scenarios for interventional cardiologists. Calcium content in coronary tree directly correlates with male sex, age, Caucasian ethnicity, diabetes, and chronic kidney disease. Intracoronary imaging is useful and necessary to understand calcific lesion features and plan the best percutaneous coronary intervention strategy. Thus, accurate evaluation of patient and lesion characteristics is crucial. For this reason, definition of calcific arc, length, and thickness can suggest the best procedure before stenting and final optimization. In our modern era, different devices are available and all are surprisingly promising.

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions.

BACKGROUND: Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure. PURPOSE: The study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT. METHODS AND RESULTS: Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ±â€¯2.77 mm2) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis. When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ±â€¯24°; Group B: 21 lesions, calcium arc 289 ±â€¯53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ±â€¯0.29 mm; group B: 1.31 ±â€¯0.52 mm, p = 0.63). CONCLUSIONS: A standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.

Intravascular Lithotripsy and Impella Support to Assist Complex LM Angioplasty.

Coronary and peripheral calcifications are associated with increased procedural complexity and suboptimal results in both coronary and peripheral percutaneous interventions. Intravascular lithotripsy (IVL) has recently entered the clinical scenario as a new technology for plaque modification, with promising results. We present a case of high risk left main (LM) percutaneous coronary intervention (PCI), in which peripheral Shockwave IVL was used to facilitate the delivery of an Impella CP via a 14 F sheath and coronary IVL was used to prepare a very calcific left main bifurcation lesion before stent deployment.

Contemporary Approach to Heavily Calcified Coronary Lesions.

Percutaneous treatment of heavily calcified coronary lesions still represents a challenge for interventional cardiology, with higher risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. Good characterisation of calcium distribution with multimodal imaging is important to improve the successful treatment of these lesions. The use of traditional or new dedicated devices for the treatment of calcified lesions allows better lesion preparation; therefore, it is important that we know the different mechanisms and technical features of these devices.

Percutaneous Trans-septal Mitral Valve-in-Ring Implantation Using a Transcatheter Balloon-Expandable Transcatheter Heart Valve With Elective Intra-Procedural Artero-Venous ECMO in a Patient With Severely Reduced Left Ventricular Ejection Fraction.

Percutaneous mitral valve-in-valve implantation is an emerging option in patients with surgical bioprosthesis failure or failing mitral annuloplasty and increased surgical risk. We present a case of transcatheter transvenous trans-septal mitral valve-in-ring (TMVinR) procedure, in a patient with severe left ventricular dysfunction and severe mitral regurgitation, after surgical mitral annuloplasty, managed with periprocedural mechanical circulatory support (MCS) with VA-ECMO.