@JReinerMD
👍Every single successful cardiac arrest resuscitation begins with immediate and effective bystander and EMS CPR and Defibrillation: we only deliver survivors back to their families if we receive survivors from their neighbors and EMS🤝…
1/7 Vascular Access for Shock-MCS. Do it the same way every time (“slow is smooth, smooth is fast”). Fluoro Femoral Head. US-guided Micropuncture access, observe micro wire advancement, perform access site angiogram (with wire left in), Preclose (single Perclose)...
1/3 “Intravascular Imaging 👁️ During Percutaneous Coronary Intervention” (by the
@ACCinTouch
#ACCIC
Team): Just Do It, Do It Often (? Always), and Do It Right: Practical Guidance and Programmatic Recommendations🤜🤛: …
Bifurcation PCI. How do you “mark” your wires? Me: side-branch wire “in” fold of towel (then flip towel open/closed as necessary to manipulate/load wire), main branch wire “outside” fold. Others?...
#radialfirst
Let them Eat (or at least Drink)! Guidelines say 4 hours NPO. Many Hospitals (oddly) still say 8 hours NPO. Surveys (unfortunately) show > 13 hours NPO: …
👍So very hard to conduct clinical trials in the Cardiogenic🫀Shock💥⚡️population (and demonstrate mortality benefit): so…immense kudos to all the
#DanGerShock
Investigators 👏. And now…on to
#RECOVERIV
🤜🤛: …
1/2 👍Back to doing buddy-operator (vs. solo)
#CTO101
cases (now with my brand new CTO-CHIP partner
@lindsey_cilia
): Case
#1
#RadialFirst
and
#LDTRA
blunt cap LAD AWE with Fighter and IVUS-Guided PCI with 3.5mm DES (to 3.7-4.2mm)…
1/2 Impella removal when no Pre-Close (which is preferred) performed.
#RadialFirst
iliac balloon🎈occlusion (with wire into SFA). Wire into Ao via Impella rewire port. Replace Impella with 10 Fr sheath and place second wire into Ao: Perclose (post-close) over each wire…
1/4 “Optimal Large-Bore Femoral Access, Indwelling Device Management, and Vascular Closure for Percutaneous Mechanical Circulatory Support” in
@AmJCardio
: (“soup to nuts”, operator-focused, and “real world”) led by
@yadersandoval
👍: …
1/6 Standardized Team-Based Care for Cardiogenic Shock...courtesy of
@behnam_tehrani
on behalf of our INOVA-SHOCK team (with additional embedded online-only Tables and Figures): ...
#waronshock
Misc Impella tips:
#1
Advance O.035in wire to Ao Root via side-arm port (in addition to POCUS) to confirm position,
#2
Secure device at same angle of entry as access (and cinch Pre-Close suture and use final Mattress suture [both hidden under dressing here]) to prevent oozing…
Love Guide extenders for
#RadialFirst
distal equipment delivery (when necessary): sometimes advanced with the help of a distal anchor balloon...or over 2-wires (wire/buddy-wire) as here...
👍
@Mechanical
Circulatory Support Devices in Acute Myocardial Infarction-Cardiogenic Shock💥⚡️Current Studies and Future Directions” by
#JakeJentzer
et al🤜🤛: …
@PinakShahMD
🤜🤛: I’ve been known to reply “Great! I’ll meet you at the bedside to evaluate the patient and we can decide the best next course of action together”. Sometimes followed by either awkward silence (if caller is not in-house)😜…or appreciation (if caller is in-house)👍…
Highlights of a 16-hour Cath Lab day?: 3 separate families’ super kind refrains: “Thank you and your family”, “Bless you”, “Did you have Dinner?” (all energizing and thoughtful comments: but
#3
was my personal favorite👍)...
Cath lab
#powermoves
💪. Calcified tortuous RCA referred after failed femoral PCI (inability to advance equipment).
#radialfirst
completed with microcatheter over workhorse (to exchange for stiff wire), Guidezilla (delivered via distal anchor balloon), and stents via Guidezilla...
"High Risk" and/or "Complex" PCI: increasingly the "new normals" in the modern Cath Lab? How do we match our skills to increasing procedural complexity? How do we estimate procedural risks (and better counsel patients)?...
AMI-CS. Outside xfer. Ostial LAD acute ST. EDP 40, BP 80 on Dopa/Levo. Impella CP. Same-site 6Fr sheath for re-look Cor Angio and IVUS optimization of outside stents (2.75 taken to 3.67 and LM places). Final ipsi run-off angio via 4F Pig, then peel-away removal...
#waronshock
#RotaTripsy
: heavily calcified LAD. IVUS wouldn’t cross. Pilot channel with Rota. Then IVUS. Then IVL via Guidezilla for more complete calcium modification. Then IVUS-guided DES…
“The Intra-aortic Balloon Pump: A Focused Review of Physiology, Transport Logistics, Mechanics, and Complications” (great IABP review for Pre-Hospital, ICU, and Cath Lab Teams👍: …
Femoral > Radial (it’s just a fad). Who needs US for access (just palpate and stick)? IVUS-OCT is unnecessary (my eyes are better). LAD stents should be 2.5mm or smaller (it’s fine). Lesion prep is a waste of time (underexpansion won’t cause any immediate harm)...
#AprilFools
1/6
#SpokeAndHub
#Shock
story: 50s Diabetes presents with acute chest discomfort/dyspnea. ECG global ischemia. HR 100s, BP 90s. Cath below at
#Spoke
Hospital. EF 45% by LV Gram...
Grateful Patient reminded me how truly amazing it is (which we often forget) to perform complex coronary interventions:
#1
on a beating heart🫀,
#2
with a semi-awake patient,
#3
via
#RadialFirst
,
#4
as a same-day outpatient procedure👍…
What are the biggest changes in your Interventional practice in the past 5 years? For me it’s
#1
: adoption of comprehensive hemodynamic assessment in CS and
#2
: adoption of routine intracoronary imaging for PCI. You?...
1/3 Joined AMI-CS LM-LAD PCI case in progress with BP 50s. Stopped in-process PCI. Placed Impella via pre-existing 6 Fr CFA sheath. Stabilized hemodynamics. Performed IVUS-guided
#imagefirst
LM-LAD PCI (via
@jason_wollmuth
single-access technique)...
#waronshock
1/4 Why use distal embolic protection (every single time) in SVG-PCI? Here’s why👇. NSTEMI. Culprit subtotal occlusion of SVG via
#LDTRA
#RadialFirst
access…
“Standardized Definitions for Cardiogenic Shock ⚡️💥 Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium”👍: …
Even if you forget (or opt not) to Pre-Close
#Shock
Impella: can always Post-Close (via multiple techniques) safely, simply, and effectively (many days later) thanks to the Impella re-wire/re-access port👍...
@ABIMcert
Wrong again? Hey
@ABIMFoundation
@ABIMcert
: remember your 2015 “we got it wrong” email? I do. 8 years later you’re still all wrong: over and over and over again. Follow your own advice (below) and
#EndMOC
…
Large-Bore Access and Closure (not just for TAVI)👍:
@EuroInterventio
: “A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study”: …
@DBarkhuff
And…since when did “community policing” become part of SEAL expertise: and…why are local “protect and serve” PDs training to be something they’re not (and should never be)🤷♂️?…