Matthew P. Cauchi, D.O., introduces the program at Sentara Rockingham Hospital and the challenges and considerations for a rural program in treating heavily calcified lesions.
thanks for everybody for for tuning in for grand rounds today. My name is Matthew Catchy. I'm one of the interventional cardiologists here at us and here are much in the blue ridge and kind of wanted to give um our experience with um with shockwave were kind of really kind of excited from uh, from a safety perspective to have this device rollout because we have some unique challenges here um kind of geographically in dealing with dealing with these really complex cases, uh complex coronary cases as as discussed in these in the prior case presentations. Um so I just wanted to kind of hit on a couple of those then go through a couple of a couple of cases that we ran into during this, during this trial trial period. So some of the specific challenges and considerations for us and kind of why we were excited about about a technology like this that's, you know, safer than conventional, a thyroidectomy, rotational and orbital a threat to me. Uh we have a fair amount of challenges kind of in a more rural environment, you know, large geographical and travel concerns harder to stage patients for procedures when they're coming in for a outpatient procedure. You know, driving an hour, hour and a half to come and see us. So having something up front that's safer that we can discuss with patients. Is, is certainly uh, you know, something that's very, very helpful to kind of be able to do a lot of these procedures um in a safe environment in a single environment instead of having to bring them back multiple times to accomplish the mission. Um You know some of the you know while while it is beautiful a beautiful drive through the through the Blue Ridge mountains. So a lot of our patients have uh issues with transportation and you know having to get here through some pretty rough terrain. So we appreciate that and try to flex our our abilities to that. Um Having flexible bandwidth with bed availability. You know our hospitals a little bit smaller. Less beds, less capacity especially through the pandemic. I felt like this was a great tool for us to be able to use during the pandemic because we didn't have to you know worry about um you know some of the issues of pulling out the rotational a threat to me. You know are we gonna worry about dissection. Do we have to have an O. R. Available? Is cardiothoracic surgery available for us? Um You know lacking an oversight, overnight outpatient facility, facilitate discharge. We have to admit all of these patients that get these high risk procedures. And when you're running low on bed space, just like everybody else is has dealt with. Um It is important to consider. Um And then you know vendors support um limited out here, you know familiar devices and processes certainly favored you know the wire balloon stent is a very familiar cadence for a lot of texts and for us. So it's it's very important to kind of uh facilitate that. It makes everything a lot easier than having to pull out a device that you know, that takes a lot of steps and a lot of a lot of moving parts that could be a problem, and I'll show that in one of my case presentations here um so really kind of the benefit to having shockwave in a more rural setting like like us, um you know, it avoids having to travel to unfamiliar healthcare systems and and cities, although you know, we're about 45 minutes away from Charlottesville and you be a that is quite the trek and dealing with, you know, some big university hospitals and systems that that can make patients uneasy so they want to get care here, you know, no matter what cost. So this is a great tool for that. Um They have family support here, you know, and just looking to improve the health and the well being of our our local community, um improving patient outcomes with, you know, this is pretty cutting edge technology and improving patient safety. I think that's one of the, you know, dr Summers pointed out, is that, you know, the devices is safer, you know, than than traditional a thyroidectomy devices. Um so certainly uh push from a patient safety perspective in this regard with great outcomes and then specific to coronary, let the trip see, being able to deliver this kind of high quality care at a local level is really important to the community uh prevents having to refer to other centres for specialized care and like I said before, the familiar cadence of being able to wire balloon and stent less equipment, less specialty training needed needed for staff. Um while this does not, you know, completely supplant other types of a threat to me, they absolutely have a role. Um This is a very familiar thing for for us and interventional lists and uh you know, the peripheral guys have been using little trip see for for a while, we do it in structural cases in preparation to tavern in the periphery to, you know, you know, be able to facilitate sheet deployment um and calcified leg arteries. So it's a very familiar cadence and I think that that is something that needs to be highlighted as well and then shorter procedure times. Um and increasing throughput without sacrificing safety or patient satisfaction. And then other things that we've kind of uh noted kind of listed here. Um So when it comes to cases, I don't I don't have, unfortunately movies did not work. So I have some still frames here, but I think it's still kind of highlights all of the stuff that we've seen and gotten into. So we had a 40 74 year old male who was admitted with a fib with RVR is actually relatively healthy for quite some time, Just hypertension. It does have known hypertrophic cardiomyopathy converted to sinus rhythm spontaneously. He really wanted to get home. He has never met his grandson who was you know born during the pandemic. They were flying in from I think Seattle and he wanted to get home to see them. They were coming that night. And um we got an echo. Is EF was previously normal or hyper dynamic and now is around 30 35%. We felt an ischemic work up was necessary but actually end up coming and it ended up getting discharged. It was stable, no engine and no heart failure and came back for an outpatient calf. Um It is imaging for the for the right coronary showed an occluded right? Um And here you can see the this is an image of the L. A. D. And you can see this area kind of where my arrow is. Hopefully you can see that this uh lesion in the L. A. D. The L. A. D. The distal led also collateralized the whole right coronary. So this is kind of a higher risk um higher risk areas applying to territories. Um Instead of just the lady territory. This is another view of it. You can see how angular ated didn't necessarily appreciate the degree of calcification um upfront in this particular vessel. Um So the operator wired the lesion. Uh And unfortunately did not yield with the balloon. Um at all. So pretty pretty significant recalcitrant lesion there. Um It was a possible edge dissection um in the distal segment. So there was some concern about, you know, if this is a really calcified lesion, what do we do in a patient with the distal edge dissection? You wouldn't do rotational hysterectomy, you wouldn't do um uh any type of a threat to me device for you know, fear of dissecting down the entire vessel. So the decision was made with, you know, to perform shockwave in this particular setting. Let the trips he was formed with a 3.5 millimeter balloon placement of a single Ds. And the patient was discharged actually the same day. Um So this could have been, you know, pretty disastrous if we had had done a rotational and correct me if there was a dissection and lost the also lost the collaterals to the right coronary. Could have been pretty pretty bad. And also doing up front a threat to me with the generation of particular matter and the worry for um slow flow or no re flow. Um In this particular situation um can certainly get you get you to do a lot of trouble um From from an ischemic s chemical standpoint. Also doing rotational at the rectum in a in a lesion that's this angular hated um could certainly get you into trouble and increase your risk of of preparation as well. So great result ended up being a same day discharge patients did great as ef actually has since recovered. Second case is a little bit more complicated as a 60 year old patient with moderate multi vessel disease came in with an honest elevation and my smoker diabetic um had a severe lesion in the distal R. C. A. You see this filling defect down here, This calcified nodule probably about 90 or 95% stenosis there. What you don't appreciate in the still film is that the rest of the artery, This this kind of tortuous segment of the artery um is also fairly heavily calcified but kind of mild to moderate diffuse disease. So the the operator so not ideal for a threat to me to deal with this more distal um lesion especially have to work through essentially if you're gonna do rotational at the rectum, E. Or or bill at the rectum, you have to burr your entire way down to the distal vessel, potentially compromising the more proximal uh segments as well to be able to treat your, you know the more distal lesion um was actually pretty difficult to wire. Um uh And after um after the original wire was placed they had difficulty getting any equipment down through the tortuous it especially through the calcification. So they end up having to switch out to a stiffer wire to provide a little bit better support. Um Had to start with a 1.2 and a 1.5 millimeter um balloons To even get anything down to the more distal lesion. Um They used a guide extension to get a little bit closer uh procedure took awhile, patient developed significant chest pain, moved around the table and he coughed. Um And unfortunately that coughing removed everything from the from the from the artery. Um So gonna have to start over the operator, you know, sized up, went up again and actually this is the first picture that he got back. Once he engaged the artery there is obviously some damage to this mid segment of the vessel. The flow in the distal vessel was pretty pretty poor so it was concerned about um dissection, concern about other uh thrombosis build up, you know as a non S. T. Elevation am I? Um So there have been some thrombosis that got kicked up. Um So the decision made here in this you know similar reason is as the first case where there was a potential issue with primary pc. I. We decided to do shockwave and shockwave the mid two distal vessel including the calcified nodule and was able to deliver three overlapping D. S. With excellent excellent results here. Um And patient went home the next day. um 3rd case interesting kind of a uh 73 year old gentleman severe lung disease on four leaders home oxygen smoked for a long time semi invasive aspirin paralysis of the right upper lung being managed by by pulmonary had moderate to severe aortic valve stenosis. Um And he underwent diagnostic cath to evaluate you know for potential Tavern was found to have these multiple severe tandem lesions in this really tortuous calcify, right coronary. He had a moderate led lesion that was I fr negative at 0.94 and moderate A. S. So the decision was made to bring him back for staged PC. I. To the R. C. A. The first attempt to uh to to bring him back and after discussion with with our interventional partners decided, you know, that rotational at the rectum ian orbital, a threat to me is not ideal given the significant tortuous city in this vessel. Um So we elected for potentially up front lit the trip see strategy. But unfortunately we were able to given the severe torture velocity, were able to wire but unfortunately not able to pass the little trip see balloon, which was kind of a learning point for us. The balloon is a little bit bigger um than than some of the other balloons that we have. So, being able to pass the pass beyond the lesion is actually really um you know, you know, as a learning opportunity for us. Um And then are, you know, we we got him off the table after kind of a prolonged attempt brought him back um brought him back and came from the federal approach instead of the radio. Um and was able to deliver our little trip see and actually had an excellent result and actually his shortness of breath, which on chronic for leaders, it's hard to kind of um to determine uh significantly better after his procedure. So, a learning point for this one was a lot of this is about guide support and trying to make sure that um were you know, where you understand that the balloon is is a little bit of a larger balloon than what we're dealing with. Um So setting yourself up for success is important, especially dealing with these tortuous right coronaries. And then the last case, I think it's the last one. So 72 year old male at an aortic stenosis work up. Peak velocity was like four or five mean gradient of four to um also had this honor deficiency anemia of unclear etiology. They've been going on for quite some time. He never had any kind of work up and send them to gi they declined to do anything until we treated as aortic stenosis. Um So we had a pre procedure, calf has left coronary tree was pretty un remarkable. His right coronary show this uh mid right coronary lesions, just e centric um kind of segment in the in the mid, in the mid here, that was I fr positive. He had no true angina symptoms. So we actually did Tavern first didn't necessarily want to do um Pc. I put him on dual. And I believe that therapy worry about the bleeding concerns with his iron deficiency anemia. So we did his Tavern first G. I did their whole pretty extensive work up, which was unremarkable. And we had a plan for stage pc out of the right the first time he was brought in via the radio approach. So and the right coronary. You know the plan was for rotational at the rectum. E. So it was radio access. And also break, you'll access, break your vein access for temporary venous pacemaker. Um And then once everything was up the, you know, wired across exchange the wire for the road. A floppy. The proprietary wire um Got everything up. The the device unfortunately would not platform outside the body. There was some kind of issue either with a burr or issue with the uh the entire device. So that was taken off another one was put on and it failed again. Um So at that point, you know the procedure was bailed on. We said you know, we'll get the vendor in here, we'll get them to look at the road of machine, make sure there's nothing. We sent a burst of the company. Um So then he comes back and We tried again. Um and we were able to get a 1.5 and 1.75 Birr after a platform failure outside first. Um we were able to get to more birds that that were that were successful down the artery multiple wire exchanges. You know, we use cutting balloon scoring balloons non uh non compliant balloons to high atmosphere. And this thing would not budge. And I this is just a complete 360 degree arc of of calcium. Um So he had this is his if you're keeping track he had a diagnostic calf And then he had a tavern and then he got brought back for APC. I. And then the road a failed. So he had radio broke. You'll access for that. And then he has radio breaking all access for this procedure and unsuccessful. And then he comes back for a third attempt with shockwave uh after the approval within the system. Um and it was probably one of the more simple procedures done in 45 minutes via the radio approach as well. So this guy had five procedures here. Um so and this is kind of the final result here. Um And then learning point. You know if a device, if the device has moving parts that can break um There was issues with both the burr and the and the and the setup from a uh from a road a rotational hysterectomy standpoint. So that was a challenge. So we were kind of really excited to have this technology here at R. M. H. You know, word of mouth is a real stronger driver of reputation around here to these patients have been around um Talking about this cool stuff that we could do at our facility and multiple patients have actually come to me and said you know we heard has did this procedure. So word of mouth is big, especially in kind of these smaller communities. Um you know, ease of use and familiar cadence is really important. Guide supports really important. We kind of learned learned that upfront procedural success was excellent. We had one failed, let the trip see kind of balloon crossing and I have two aboard the procedure, but otherwise you know, successful. Um and then facility the same day discharge for a couple of patients did not require coordination with C. T. S. Um and just allowed us to be able to deliver high quality care at a local level. So we're really kind of excited to be able to to to utilize this equipment. So um that's all I have from the from the Blue Ridge.
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