Cath Lab Digest

Richard Heuser, MD and Shishir Murarka, MD*

*Banner Estrella Medical Center, Phoenix, Arizona

CLINICAL HISTORY

Our patient is a 59-year-old male who has a history of a large anterior wall myocardial infarction in 1988. On September 30, 2009, he had a stent placed to the circumflex coronary artery. There was stenosis of the right coronary artery with patent previous stents. The left anterior descending artery (LAD) was chronically occluded in the distal segment. His left ventricular function was diminished with an ejection fraction of 35% and anterior hypokinesia was noted. A month later, the patient presented with acute congestive heart failure (CHF). He had a new apical thrombus. After anticoagulation was started, he had an episode of Amaurosis Fugax. This responded to enoxaparin and warfarin therapy. The patient presented 6 months later due to CHF exacerbation. His ejection fraction deteriorated to about 15%. An automatic implantable cardioverter-defibrillator (AICD) and synchronized pacemaker were placed. We also considered recanalizing the presumed occlusion of the circumflex artery.

On May 4, 2010, we attempted to recanalize the patient’s circumflex artery, however, just the presence of the guiding catheter in the left main artery resulted in hypotension and near respiratory arrest. He was brought back to the catheterization laboratory the next day, and, because of acute exacerbation of his CHF, we placed the Impella device (Abiomed Inc., Danvers, Massachusetts) via the patient’s left groin.

He had significant disease in the proximal LAD prior to the total occlusion, which was interrogated with intravascular ultrasound. There was 80% stenosis of the proximal LAD. A Cougar wire (Medtronic, Inc., Minneapolis, Minnesota) was placed in the LAD, followed by a 3.5 x 24 mm Endeavor stent (Medtronic), which was postdilated with a 4 x 15 mm high-pressure balloon. An extra back-up guide (Medtronic) was placed and a 3 x 10 mm anchoring balloon was inflated in the proximal portion of the circumflex artery. We used the Provia 6 (Medtronic) and then the Provia 9 wires, with success. We then exchanged for a Transit catheter (Cordis Corp., Miami Lakes, Florida) and distally went in further with a Terumo Gold wire (Terumo Medical, Somerset, New Jersey). The Gold wire was then exchanged for a Fielder XT (Asahi Intec/Abbott Vascular, Redwood City, California), and a 1.5 x 6 mm balloon was placed. We could see that we were under struts from the previously placed stents. We then were able to perform multiple balloon inflations, first with a 1.5 x 5 mm and then an AngioScore balloon (Angioscore, Inc., Fremont, California), and then placed a 3.5 x 18 mm, a 3.5 x 30 mm and several other Endeavor stents. At the end of the procedure, the occlusion went from 100% to 0%.

This case demonstrates the ability to use the Impella device to treat high-risk chronic total occlusions and to introduce several extremely torqueable and maneuverable wires by Medtronic.

Among other features, the Provia wires offer many enhancements over the existing severe occlusion wires on the market.

The ProVia Wires:

ProVia: Family of crossing wires designed for the most difficult lesions. Provides overall “best in class” torque and lesion penetration performance due to:

Accu-Core technology: Designed to improve wire torque and crossing ability:
• High torque core process: Eliminates inherit wire bias and stress to maximize torque response
• Grind Design: Increased length of distal tapers to optimize torque transmission and control
• Co-axial coil design: Core wire is centered all the way to distal tip for improved steering
• Rounded tip design: Which improves torque and helps eliminate “whipping”
• Improved coil pitch: Tighter design improves steering and control in confined spaces.

– Available in 3, 6 9 and 12 gram weights
– Round core to tip
– Co-axial spring design
– Improved taper tip to 0.009 (ProVia 9 and 12)
– Hydrophobic tip on all ProVia wires

Family of crossing wires (ProVia 3, 6, 9 and 12) designed for difficult lesions and competes against:
– Miracle Bros (3, 4.5, 6 and 12)
– Confianza/ConfianzaPro wires (9 and 12)
– Cross-It family

Engineered to be overall “best-in-class” in terms of:
• Torque performance
• Lesion penetration and cross ability
• Increased length of distal tapers provides optimal torque transmissions without giving up column support
• Improves ability to steer in and around tortuosity

------------------------------------------------------------------

Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at The Johns Hopkins Hospital in Baltimore, Maryland.