TCTAP C-238 Fish and CHIP: Concurrent Percutaneous Left-Ventricular Thrombus Retrieval and Complex Coronary Intervention With Hemodynamic Support
Recommended Citation
Fang JX. TCTAP C-238 Fish and CHIP: Concurrent Percutaneous Left-Ventricular Thrombus Retrieval and Complex Coronary Intervention With Hemodynamic Support. J Am Coll Cardiol 2025; 85(15):S493-S495.
Document Type
Conference Proceeding
Publication Date
4-22-2025
Publication Title
J Am Coll Cardiol
Abstract
Clinical Information Relevant Clinical History and Physical Exam: A77-year-old female with ACS, LM-triple vessel disease, LVEF 20% and a 1.8cm LVT(Figure 1), with prohibitive surgical risk and cardiac index of 1.5 L/min/m2on inotropic support, was offered percutaneous coronary intervention (PCI) with concurrent thrombus aspiration with the AngioVAC system (AngioDynamic, USA) per heart team decision. [Formula presented] Relevant Test Results Prior to Catheterization: ECG: TWI I, V5-V6, late precordial R transition Echo: LVEF 20%. Apical aneurysm. 1.8 LV apical thrombus. Moderate mitral regurgitation. Relevant Catheterization Findings: Elevated filling pressures. RA 10mmHg PA 52/12 mmHg mean 32 mmHg, PCWP 28 mmHg Fick Cardiac output/index 2.6 / 1.5 Coronary arteriogram: LM bifurcation medina 1,1,1 disease mLAD subtotal occlusion pLCx 70-80% calcified lesion pRCA CTO, left-to-right collaterals [Formula presented] Interventional Management Procedural Step: Right femoral vein access with a 26-French sheath with hemostatic valve (DrySeal, Gore Medical USA) preclosed with two proglides (Abbott Cardiovascular, USA) was obtained. Biradial accesses were used for cerebral embolic protection (figure 2, panel A). Transeptal puncture(B) and septostomy(C) followed by balloon-assisted tracking(D) brought a 22 French AngioVAC cannula into the left atrium (E), followed by mitral valve crossing to reach the LV apex via a Confida wire(G-I) (Medtronic, USA), followed by thrombectomy, all under transesophageal echocardiography (TEE) guidance (H-J). Blood was returned through an oxygenator into a 15 French cannula place in 16 French Dryseal sheath via right femoral artery access preclosed with proglides. After thrombectomy, the suction cannula was pulled back into the right atrium with the funnel retracted. At a flow rate of 3.5 liters-per-minute, it served as a venoarterial-extracorporeal membranous oxygenation (VA-ECMO) circuit (figure 3, panel A). Complex high-risk indicated PCI (CHIP) was performed via left femoral artery access to left anterior descending artery (LAD), left circumflex artery (LCx) and LM bifurcation (B-P) with good result on final angiogram (figure 4, panel A). Contrast echocardiography showed no further LV thrombus (B) and unchanged mitral regurgitation (C) after the thrombus was fished out (D). The patient recovered and was discharged. [Formula presented] [Formula presented] [Formula presented] Conclusions: Acute coronary syndrome (ACS) with concurrent left main bifurcation disease, reduced left ventricular ejection fraction (LVEF) and left-ventricular thrombus (LVT) is a challenging situation where the micro axial flow pump for supporting coronary intervention is contraindicated owing to embolic risk. Off-label AngioVAC use for concurrent left-sided thrombectomy and hemodynamic support for CHIP is possible. Operator proficiency with large bore access and careful cannula positioning to avoid suctioning is required
Volume
85
Issue
15
First Page
S493
Last Page
S495
