ABOUT THIS EPISODE
This MurmurMD case discussion features Dr. Chris Brown and Dr. Christian McNeely walking through a high-risk PCI case where the hardest part was not just the calcium, it was deciding when and how to intervene safely.
The patient was an 82-year-old frail female who presented with chest pain and NSTEMI. Angiography showed heavily calcified distal left main disease, proximal circumflex disease, a tight calcified mid-LAD, moderate LV dysfunction, and an occluded RCA. She was transferred for surgical evaluation, but then developed neurologic changes while on heparin and was found to have a small amount of bleeding in a prior meningioma resection bed.
That created a difficult clinical problem: surgery was no longer feasible, anticoagulation and antiplatelet therapy carried real neurologic risk, and the coronary anatomy still needed treatment.
The discussion focuses on practical decision-making in a case with limited bailout options: waiting for stable neuro imaging, rechallenging heparin, checking rapid CYP2C19 genotype to support a short-DAPT plan, using Impella support, planning access with CTA, modifying severe calcium with rotational atherectomy and Shockwave IVL, preserving the circumflex with a nano-crush style strategy, and carefully managing closure and anticoagulation reversal.
KEY TOPICS
• Frail elderly NSTEMI patient with severe calcified left main/LAD/circ disease
• Neurologic complication after heparin in prior meningioma resection bed
• Timing PCI after stable serial neuro imaging
• Short-DAPT planning and rapid CYP2C19 testing
• Why hemodynamic support was used
• CTA planning for calcified tortuous iliac access
• Rotational atherectomy to facilitate equipment delivery
• IVUS delivery challenges and imaging limitations
• Shockwave IVL for distal left main/LAD/circumflex calcium
• Rewrap advantage when moving IVL from LAD to circumflex
• Nano-crush style left main bifurcation strategy
• Deciding whether to treat the remaining RCA CTO
• Hybrid closure strategy and partial protamine reversal
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CHAPTERS
00:00 – Case setup: frail NSTEMI patient with limited options
01:16 – Neuro bleeding complication and why surgery became high risk
02:18 – Waiting, serial scans, and timing high-risk PCI
03:08 – Short-DAPT planning and rapid CYP2C19 testing
04:18 – Why Impella support was chosen
04:46 – CTA planning for calcified iliac access
06:09 – PCI plan: LAD priority with circumflex involvement
06:31 – Rotational atherectomy to start the case
07:05 – IVUS delivery challenges and calcium assessment
09:02 – Shockwave IVL for severe calcified disease
09:37 – Rewrap performance and treating the circumflex
10:09 – Nano-crush style bifurcation strategy and final result
10:31 – What to do with the RCA CTO?
12:11 – Closure strategy, ACT control, and protamine reversal
13:18 – Outcome and final takeaways
#ComplexPCI #HighRiskPCI #LeftMainPCI #NSTEMI #Impella #ShockwaveIVL #RotationalAtherectomy #CoronaryCalcium #IVUS #BifurcationPCI #MurmurMD
