National Virtual Fellows Course: Complete Revascularization in High-Risk PCI and Cardiogenic Shock Best Practices

Shon Chakrabarti, MD, MPH hosts this virtual course for current and prospective interventional fellows to learn from experts in the field of complex coronary intervention and mechanical circulatory support. The featured speakers are Kevin Croce, MD, PhD, Sandeep Nathan, MD, MSc, FACC, FSCAI, and Alex Truesdell, MD, FACC, FSCAI. Topics range from complete revascularization in high-risk PCI to best practices for large-bore access and management of cardiogenic shock.

Shon Chakrabarti begins the course with an overview of Abiomed, the history of Impella® technology, supporting clinical evidence, and a glimpse into future technology directions for the Impella platform.

Dr. Croce, director of the CTO and complex coronary intervention program and director BWH Translational Discovery Laboratory at Harvard Medical School focuses on high-risk PCI with a presentation titled “When to Use MCS and the Benefits of Complete Revascularization.” He explains that surgical ineligibility is the strongest factor influencing mortality in high-risk PCI and emphasizes the importance of involving a multidisciplinary heart team to determine the best treatment strategies for patients. He discusses the well-recognized benefits of complete revascularization in multivessel high-risk PCI and explains that image-guided PCI can enhance the efficacy of multivessel and high-risk percutaneous revascularization. His advice for fellows as they go out into practice is, “Think about how well trained you are for physiology and intravascular imaging… I really think this is really where our field is going.”

In the discussion following Dr. Croce’s presentation, the physicians share their experiences in building robust heart teams and developing collaborative relationships with surgical teams. Dr. Truesdell emphasizes the importance of always growing in your practice, noting that 5 years out of his fellowship, 50% of the things he was doing he was not trained on during his fellowship.

Next, Dr. Nathan discusses critical tools, techniques, and skills for large-bore vascular access, explaining that large-bore access, vascular closure, and hemostasis techniques are essential skillsets for the contemporary interventional operator. Dr. Nathan is an associate professor of medicine and medical director of the cardiac intensive care unit, director of the interventional cardiology fellowship program, and co-director of the cardiac catheterization laboratory at the University of Chicago. Dr. Nathan emphasizes that bleeding drives mortality post-PCI and he focuses on modifiable risk factors for predicting bleeding following vascular access, notably puncture technique, sheath size, medication, and hemostasis. He describes vascular closure devices and best practices for large-bore femoral closure, yet emphasizes, “Meticulous access technique obviates a lot of the risk.” Dr. Nathan tells fellows that ultrasound mapping/guidance, micropuncture technique, DSA angiography and fluoroscopic roadmapping are essential techniques to use in most, if not all cases.

Dr. Truesdell focuses on cardiogenic shock, explaining that when patients are in cardiogenic shock and actively dying, it is not the time to learn or practice complex PCI and vascular access skills. “You don’t show up for the big game never having practiced.” Dr. Truesdell reviews how care for cardiogenic shock has evolved and describes the importance of focusing on circulatory support and ventricular support as well as coronary perfusion in patients with cardiogenic shock. He explains the importance of matching the right device(s) to the right patient at the right time and emphatically emphasizes the need for using a Swan-Ganz in every single shock patient and the importance of being familiar with hemodynamic parameters (e.g., CVP, PCWP, PAPi, CI, SVR, CPO).

Circling back to the importance of the heart team in managing patients, Dr. Truesdell explains, “I’ve learned so much from my surgical colleagues, and I’ve learned so much from my heart failure colleagues, my critical care colleagues…there’s not one of us in any of those specialties that possess all the exact same knowledge as the other, so the more you can leverage the knowledge of your partners and peers, the better you’re going to be and the better you’re going to be for your patients.” Dr. Truesdell also emphasizes the importance of standardized approaches and protocols for providing all patients with the same access to, timeliness of, and quality of care.