Interventional Challenging Cases
The ACC is no longer accepting Interventional Challenging Case submissions. Accepted Interventional Challenging Case will be featured at ACC.22, where presenters will share their case with colleagues from around the world.
Selected case presenters will have 10 minutes to present followed by 5 minutes of discussion and debate with the moderator, panel of experts and your peers. Cases must be submitted in PowerPoint format. Be sure to include a brief history including non-invasive testing, angiogram information and interventional details. Please note: cases submitted to a category that does not match the subject matter may be given a low score by the reviewers.
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Sample Interventional Challenging Cases
First Report of Transfemoral JenaValve Implantation for Severe Aortic Regurgitation in a Patient With a HeartMate II LVAD
Patient Initials or Identifier Number: FS
Relevant History and Physical Exam: A 80-year-old male with ischemic cardiomyopathy with HeartMate II implantation in 2017 presented with high frequency of power spikes and hemolysis.
Relevant Test Results Prior to Catheterization: The patients underwent echocardiographic ramp test showing limited change in LVEDD despite speed increase, transesophageal echo (TEE) demonstrated moderate-severe aortic regurgitation (AR) with a regurgitant volume of 59ml, and AR throughout the cardiac cycle. A preprocedural CT showed no evidence of thrombosis in the outflow graft. It was hard to differentiate if pump thrombosis or AR caused the clinical syndrome and the working diagnosis was that both processes existed. The patient was scheduled for transcatheter aortic valve replacement (TAVR) followed by subcostal pump exchange. CTA revealed suitable femoral and valvular anatomy for TAVR, but limited aortic valve calcium to anchor a commercially available self-expanding or balloon expandable valve. Therefore, a 27 mm JenaValve was selected because its locator design reduces the risk of valve embolization.
Relevant Catheterization Findings: No relevant catheterization findings.
Interventional Management: The delivery catheter was advanced through the 18Fr introducer sheath to the sinotubular junction. Next, the sheath was retracted into the descending aorta exposing the valve. The catheter was deflected to allow coaxial alignment. A C-arm sweep was performed to ensure the locators were oriented correctly. Adjustments to the locator position relative to the native leaflets were made using the controller handle which allows for rotation of the valve around its own axis prior to deployment. Final alignment and engagement with the cusps were confirmed with selective cusp angiograms and TEE guidance. The valve was deployed without any changes in LVAD speed. Final TEE assessment showed minimal residual AR. This first report of transfemoral JenaValve deployment in a patient with pure native AR and a destination LVAD demonstrates the feasibility and potential of this technology for this high-risk patient population.
"RotaTripsy" – Combination of Rotational Atherectomy and Intravascular Lithotripsy For Treatment of Undilatable Severely Calcified Lesions in Chronic Total Occlusion of Right Coronary Artery
Patient Initials or Identifier Number: 001-AKC
Relevant History and Physical Exam: A 61-year-old non-diabetic male with hypertension had complaints of crescendo chest pain on exertion over a month.
Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed right bundle branch block (RBBB) with sinus rhythm. 2D ECHO showed normal LVEF with normal valves and pressures.
Relevant Catheterization Findings: Angiography showed 100% Proximal Right Coronary Artery (RCA) Chronic Total Occlusion (CTO) with severe calcification, and moderate disease on left side.
Interventional Management: Patient was planned for intervention to the RCA. Bilateral injection technique with bilateral radial approach using right side 7F Transradial Terumo slender sheath and AL1 guide and diagnostic left radial JL3.5 was used. With the antegrade escalation wire technique, extremely heavily calcified RCA CTO was crossed using FineCross Microcatheter and XT-A wire.
Despite using multiple noncompliant balloons and 2.0 mm OPN balloon at 40 atm, stenosis failed to dilate, so rotational atherectomy with1.25 mm Rotaburr was done. Repeat use of 2, 2.5 mm noncompliant balloons and 2.0 mm OPN balloon at 40 atm, failed to dilate the lesion and showed "dog-bonning" of the lesion. Finally Intravascular Lithotripsy (IVL) using Shockwave Balloon was used. Using mother child catheter-Guidzilla, 3.0 mm x 1 cm IVL balloon advanced and inflated at 4 mmHg - 2 cycles of IVL done with bursting of IVL balloon. Post IVL further balloon inflation was done successfully using 2.5 mm angioplasty balloon.
Post IVL Optical Coherence Tomography (OCT) showed both severe superficial and deep calcium within the lesion with calcium cracks and dissections in RCA with an area of ectasia with presence of intramural hematoma. 3.0 X 34 mm Resolute Onyx stent was deployed with adequate post dilatation. Post stenting OCT showed well apposed stent, no evidence of malapposition or edge dissection with Minimum Lumen Area (MLA) of 7.37 mm2 with diameter of 3.06 mm at distal part of stent and 3.69 mm diameter at proximal part of stent with excellent end result.
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