Thread by @ajaykirtane

1/In a session at #TCT2018 I saw a case of LAD atherectomy in a patient with open RCA/LCX, normal EF, and no valvular disease. Hemodynamic support was used. The stated rationale was that the patient was a complex patient with comorbidities. #CHIP

This really bothered me.

2/To me (& others in the room who spoke up), this use of support spoke to the fact that there has been some misunderstanding of the #CHIP concept in interventional cardiology as originally illustrated in this slide below, which we published in our 2016 @CircAHA manuscript

3/The CHIP concept (link below) is about recognizing what patients we can potentially help through the appropriate use of PCI, and learning/using the techniques and tools to perform these procedures efficaciously and safely.

ahajournals.org/doi/full/10.11…

4/The CHIP concept (as originally conceptualized in @JWMoses office!) has never been about a specific technique or device(s), or even a specific class of devices. We tried to eludicate that in the manuscript as shown in the figure below.

5/You will notice that in that manuscript, there is no mention of the CHIP acronym. That is not by accident, reflecting conscious effort (credit to @CircAHA editors) to dissociate the concept of more appropriate use of coronary revasc from specific devices associated w CHIP.

6/When I saw this case being presented, I felt like saying “NOOOO!!! Not every CHIP case or surgical turndown needs hemodynamic support!!! That’s not AT ALL what we meant!!!”

I then pointed this out, albeit a little bit more professionally ;)

7/The operator proceeded to describe the case.

Atherectomy was done smoothly, and the patient was doing well.

Then after an 8 atm inflation w/appropriately sized balloon, there was an Ellis Type III perforation that required balloon tamponade and eventually a covered stent.

8/During balloon tamponade/covered stenting, the pulse pressure dropped, but the support device maintained the MAP, exactly like it’s supposed to do (see below different patient).

The patient did not arrest, a pericardial drain was placed, & the operator could complete the case

9/Having seen the angiograms on this case, I believe that most *experienced* operators would have been able to rapidly tap the pericardium and seal the perforation without needing hemodynamic support, OR would have been able to put in support had it been needed on standby.

10/But operator experience is a real issue. Do we do yearly simulation of these complications for those with less experience? Or do we just sign off on interventionalists who do <50 PCI cases per year? When was the last time you had an Ellis Type III perforation in the lab?

11/Do you mentally prepare for a complication in your tougher cases before you start? Are there covered stents in the room? Have you ever used one? Are all operators facile in hemodynamic support (or even have access to the devices)? Is your staff trained to manage them?

12/Based upon variability in care/operator experience that I’ve seen (& the perforation severity), it is clear that many operators *could have lost* this exact patient without a hemodynamic support device that allows for more time to tap pericardium & troubleshoot the perforation

13/I still feel strongly that a case of typical LAD atherectomy in a patient with normal ventricle, open RCA/LCX, and no valvular disease should not need routine hemodynamic support, and moreover exposes the patient to a risk of vascular complications.

14/It may be a CHIP case, based upon the lesion, patient comorbidities etc, but not all CHIP requires support.

I’ve felt a lot of folks feeling the same way and heard more and more of this at #TCT2018 than I've heard before.

15/But it’s also true that in this particular case, the support device clearly helped save the patient’s life, who went on to have a good outcome.

This is ultimately why we need to do so much more training and research, as we outlined below when we wrote the original manuscript.

16/We need to better identify who to treat, and how. We need to know WHEN to use which techniques and devices, and in whom (guided by evidence). And if we’re going to use specific techniques and devices, we need better (not worse) access to them as well as training on them.

17/And we need true complications training that emulates that of other fields outside of Medicine.

More to come…