Balloon Pulmonary Angioplasty is feasible therapeutic option for CTEPH patients with inoperative disease-Ehtesham Mahmood

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Proceedings of Pakistan Live 2019 held at Lahore
Balloon Pulmonary Angioplasty is feasible
therapeutic option for CTEPH patients with
inoperative disease-Ehtesham Mahmood

LAHORE: Dr. Ehtesham Mahmood from USA delivered the key note lecture on New Horizons in the treatment of Pulmonary Hypertension during the Pakistan Live 2019 held at Lahore on 4-6 April 2019 organized by Pakistan Society of Interventional Cardiology. He discussed the diagnostic work up for CTEPH and pointed out that surgical principles are now well established. He then referred to the surgical classification for CTEPH. Balloon Pulmonary Angioplasty has about 5.8% mortality. Sharing the Japanese experience he stated that in a study of 88 patients, the mortality was 1.8%.

He then spoke about image guided treatment, physiology guided treatment at University College San Diego, talked about tools for balloon angioplasty for BPA. He also referred to the complications, BPA registry, surgical history and indications for BPA, quality of life and exercise tolerance. His conclusions were that BPA is feasible therapeutic option for CTEPH patients with inoperative disease. It should be physiological based and it is cost effective.

Earlier Dr. Bilal Murad from USA spoke about TAVI patient’s selection, Tips and Tricks for optimal outcome. Dr. Mohammad Munawar from Indonesia discussed indications and technique for LAA occlusion. Dr. M. Raza from USA spoke about interventional strategies for mitral and bicuspid regurgitation. Another presentation by Dr. Bilal Murad was on TAVI in low risk patients and bicuspid valve.

In the other session Dr. Sohail Khan from UK presented an unusual case of ACS. It was a thirty two years old female smoker with three weeks of postpartum. She had retrosternal chest pain for three days. Her LV ejection fraction was 52%. Her coronary Angio was don. Then there was a discussion on how to manage this case, whether it was atherosclerosis or coronary spasm. During the panel discussion it was pointed out that before Angio, Echo is helpful. It could be myopathy. Intra coronary imaging can be good for diagnostic purposes. If there was no angiographic thrombosis, it could be vasculitis. One can opt for stenting IVUS to get the patient out of trouble. One of the options could be bail out CABG as primary strategy. There are PCI problems with the sizing of the stents. The presenter then remarked that this patient was managed medically and ECG at four months was normalized and the IMH healed. His conclusions were that spontaneous IMH is a rare cause of myocardial infarction. We should be aware of its diagnosis. Mean age of the patients is about fifty years, 90% are female and 70% of these patients present with STEMI. IVUS aids in diagnosis. On clinical evaluation the patient is doing well for the past eighteen months. It was further emphasized that medical therapy was the best way to treat such patients.

Dr. Nadir Khan from Army Cardiac Center Lahore presented a case of 59 years old male who was suffering from diabetes and hypertension and was admitted with angina. He had totally occluded OM branch, critical disease in middle LAD. He then discussed how he treated the LMS bifurcation. After consulting two cardiologists in the surgical meeting the patient was referred for surgery but the patient refused surgery. One of the participant asked if the facilities of angioplasty were not available, will the patient still be referred for surgery.


Dr. Nadir then explained that IVUS in LMS imaging was done. There was heavy plaque burden. Artery was dilated. In pre dilated CS, we deployed circumflex stent. Left Main to LAD was stented and he then showed the spider view of the procedure. Dr. Asad Pathan remarked that two stents strategy could have more mortality. Final kissing balloon may have helped.

This was followed by live presentation from China by Dr. Wu. This session was moderated by Dr. Bashir Hanif. The patient was seventy five years old male. He had effort chest pain for the last four months. He was smoker and suffering from hypertension. He then discussed the management strategy. The patient had multivessel disease with calcification. Spider view was shown again. It had a very critical stenosis and was a very challenging case. It could be three vessel disease or two vessel disease. The patient may need more stents and Rota will increase the cost further. The surgical options were discussed in detail and it was pointed out that use of ROTA will increase the cost further which has now become a major issue. Cost must be kept in mind in case of extensive calcification.

Dr. Shamim from Saudi Arabia delivered his talk on CT indications. Symptoms, ischemia related to CTO are some of the indications. In total chronic occlusion PCI should be performed. He laid emphasis on careful review of the angiogram, dual injection, and dual catheter angiography. He also discussed the ante grade approach. Some of the learning points were parallel wire technique. Asia Pacific Algorithm for CTO crossing was also discussed in detail.

Dr. Seung Woon Rha from Korea made a presentation on four approaches for crossing CTO. He highlighted the choice of preferred crossing strategy before the procedure, discussed retrograde MC set up and choosing retrograde channels. He also referred to retrograde wiring with cross air. For this higher push ability is required. He also referred to wire choice and externalization options, pre dilatation besides successful stenting.

The next in the programme was a live demonstration from Singapore and the expert’s team here included Dr. Faheem Jafary from Pakistan. The patient was ninety one years old women hypertensive and hyperlipidemia. She had myocardial perfusion scan in 2006. She had somewhat acceptable results. Patient remained well with stable renal function. The case was discussed by the Heart Team. Surgeon declined CABG, hence medical therapy was discussed with the family. It was decided to do PCI. She had severe left main disease but had TIMI-3 flow. After the procedure there was good flow in the LAD as stent was placed in the left main LAD. The procedure lasted three hours. Biotronic DE stent was used. It was further stated that most stents now have good expansion profile. The case was very well managed with good results.

Dr. Parag Doshi from USA made a presentation on Approach to CTO the Ante grade wire escalation: Dissection and re-entry. Tips and Tricks. He pointed out that pre procedure high quality diagnostic angiogram is essential. One should have a thorough review of the angiogram, trained staff and CTO Tool box. Hydration is also important. The patient should be pre-loaded with DAPT. One should always engage RCA before LCA. It must be ensured that all CTO equipment and tools are available in the room. It is also important that one should not schedule too many procedures. Minimize or stop un-necessary ante grade injections. He then discussed the classifications of coronary guide wire conventional and a task specific micro channel crossing wires. He also talked about first generation directed penetration wires and second generation directed penetration wires, Knuckle and Fenestration wires.

The next session which was moderated by Prof. Nadeem Rizvi was chaired by Maj. Gen. Azhar Kayani alongwith Prof. Ambar Malik. Dr. Masood Sadiq presented a live case. The patient was a 69 years old male, hypertensive who had CABG. He pointed out that they were now doing about hundred CTO procedures a month with 90% good results. The reported success rate in USA is about 85%. It was also pointed out that one can do three PCIs at the cost of just one CTO. Gen. Azhar Kayani said that he keeps check on the budget. I select the case for CTO. Such cases should be referred to only those who only do CTO. Gen. Azhar Kayani further stated that for structural heart programme one needs a dedicated team. Prof. Khan Shah Zaman remarked that we should have a set up for our adult congenital heart disease programme. Surgical options are only if there are multiple openings. In some cases a bigger size device will be inserted. He also talked about ASD and VSD devices and pointed out that most surgeons are reluctant to take such cases. The case they showed and managed was a complex congenital case which is not easy to manage. Speaking about management of patients with STEMI and high thrombus burden, Dr. Ahmad Kasim from Saudi Arabia remarked that PCI is the best option and Grade-5 needs stratification. Reperfusion failure at tissue level was also discussed. He then talked about distal embolization, bail out manual aspiration. Red thrombus was aspirated with the deployment of two stents. It is a simple technique but one should know how to avoid stroke.

In how to treat the case session Dr. Bilal Murad discussed the management of 68 years old male who had five vessel disease. Dr. Asad Pathan discussed CAD or AS which patients to treat first in symptomatic cases. He also spoke about procedural risk of TAVI. Recent registry of TAVI has 577 patients of which 64% had CAD. There is high mortality if EF is less than 30%. He also talked about the timing of potential PCI before and during TAVI procedure. Apart from TAVI, CTO and PCI are the other options in such cases. Dr. Magdi opined that redo surgery is not a good option hence he will go for PCI. Tackle aortic stenosis with TAVI he added.

In one of the sessions there was a live demonstration of structural heart programme from Mount Sanai Hospital in USA. The patient was a seventy one years old male who had aortic valve replaced three years ago. The patient refused surgery. Subsequently he underwent PCI of the RCA. He was now presenting for staged PCI. Rota Pro was used first. Rotation Atherectomy was done. In large vessels like this, we do not opt for DA, they remarked. They also talked about BIFURCAID App and showed minicrash technique. Dr. Sharma also gave details of structural heart programme at Mount Sinai Hospital. In case of left main calcified lesions, no CABG should be attempted again.