Calcific Plaque in Acute MI – Too Hard to Break

About the Patient and condition

A 70-year-old male known diabetic and hypertensive was admitted in the ER at Apollo Hospitals, Chennai in midnight with complaints of compressive chest pain since previous night and also developed breathlessness and cough.

Case Scenario

The patient was admitted under Dr. G. Sengottuvelu, Senior Interventional Cardiologist at Apollo Hospitals, Greams Road, Chennai. Patient was diagnosed with ACS-AWMI and pulmonary edema and was loaded with anti-platelets. Initial evaluation revealed elevated BNP levels, increased Creatinine level and Wall motion abnormality with Moderate LV dysfunction. The patient was taken up for primary PCI.

CAG revealed calcified proximal LAD with 100% occlusion. The total occlusion of the LAD was opened up achieving flow, as an emergency procedure. But the lesion could not be fully opened with a balloon.

Today we have several devices to treat calcium,namely Rotablation, Rotapro, Intravascular Lithotripsy (shock wave), cutting balloon, OPN balloon, and LASER.

In this challenging situation we decided to adopt IVL which couldn’t cross the lesion. Hence it was decided to use Rotablation first to ablate the superficial calcium. Following this, shockwave lithotripsy balloon was used to fracture the deep calcium.

Patient underwent combination of shockwave IVL and Rotablation assisted PCI to LAD establishing TIMI 3 flow.

Calcified lesion – A challenge

Heavy Calcium is a limitation to perform conventional Balloon Angioplasty and stenting. It can sometimes be encountered in patients with Acute MI and it becomes difficult to open the occluded artery. Although Rotablation has been available with us for long time, it is useful only for superficial calcium modification. The newly available shockwave intravascular lithotripsy is extremely useful to deal with deep calcium. With availability of several devices such as rotablation atherectomy and the newly available Intravascular Lithotripsy (IVL) it is possible to successfully open highly challenging calcified lesions.

Shockwave Intravascular Lithotripsy (IVL) System

The Shockwave Intravascular Lithotripsy (IVL) System is a new balloon catheter that contains integrated lithotripsy emitters, which can break up hard materials (calcification) that restrict blood flow to the heart. The lithotripsy emitters at the end of the catheter create pressure waves that are intended to break up the calcification that is restricting the blood flow in the vessels of the heart.

Rotablation

Rotablation is an already existing procedure that attempts to “drill out” a narrowing in a coronary artery which might not otherwise respond to balloon. A specially-designed burr is used to grind away the blockage.

Expertise at Apollo Hospitals

The Cardiology department at Apollo Hospitals is regarded as one of the best in India that caters to patients from all over the globe. Dr. Sengottuvelu and his team are highly experienced in dealing with complex challenging stenting and newer devices. He was the first to introduce the Intravascular Lithotripsy system in India.
This is one of the rare cases, where a 70-year-old patient had heavy calcium along with thrombotic occlusion of LAD, causing Acute AWMI.

• The presence of calcium and thrombus is a difficult situation to treat, as thrombus needs soft dilatation and calcium needs aggressive dilatation.
• This patient needed usage of combination of devices namely Rotablation and Shockwave to treat superficial and distal calcium
• Adequate calcium preparation is important before stenting to get good long term result. In this case excellent result was obtained after calcium preparation with rotablation and shockwave followed by stenting.
• This patient is now on periodic follow up and doing well clinically with improved LV function.