2. Ted Feldman MD, FACC, FESC, FSCAI Disclosure Information The following relationships exist: Grant support: Abbott, BSC, Edwards, St Jude, WL Gore Consultant: Abbott, BSC, Coherex, Edwards, Intervalve, Diiachi Sankyo-Lilly, WL Gore Speaker: Boston Scientific Off label use of products and investigational devices will be discussed in this presentation

3. Holmes et al Circ 102:517,2000 Risk Factors for PTCA Hospital Death NY State Database 1991-94 When tested in a stent era population of 4063 procedures this model predicted both hospital & long term outcome

5. Poor LV Function

6. PRE Post IV NTG Post PCI Post Lasix LVEDP = 36 mmHg LVEDP= 16 mmHg LVEDP=31 mmHg LVEDP=22 mmHg chest pain Remaining coronary circulation POST PCI Poor LV Function

7. Assessing PCI Risk  Patient LV function IABP access Renal function Valve disease  Lesion Type C vs Type C + vs Type C +++ Syntax score What’s it connected to? Bail out options?  Operator  Patient LV function IABP access Renal function Valve disease  Lesion Type C vs Type C + vs Type C +++ Syntax score What’s it connected to? Bail out options?  Operator

8. Assessing PCI Risk

9. High Risk Anatomy Low Risk Patient Low Risk Anatomy High Risk Patient High Risk Anatomy High Risk Patient

10.  83YO male  myocardial infarction and cardiac arrest 1993  biventricular pacer/defibrillator 2004  ischemic cardiomyopathy EF of roughly 5 % on echocardiography on continuous natrecor until recently atrial fibrillation  admitted to other hospital 3 days ago with chest pain NSTEMI, taken for balloon angioplasty IABP placed  unable to inflate balloon in the circumflex artery  Patient then transferred for rotational atherectomy

12. Pre Rotational atherectomy 1.5mm burr

13. Post rota stent at 22atm

15. Assessing PCI Risk

18. Components of the SYNTAX Score Number & location of lesions Tortuosity Thrombus Bifurcation Total Occlusion 3 Vessel Left Main Dominance SYNTAX score Calcification EuroInterv 2005;1:219-227

19. Points +6 +5 +3.5 +2.5 +1.5 +1 +0.5 Points added based on dominance x location of lesion: Lesion Location EuroInterv 2005;1:219-227

20. Technical Cognitive Philosophical Avoiding & Managing Complications  Talk to your patient before, during, & after catheterization read the c hart  Plan the case equipment environment support  Call a failure a failure Learn how to say I’m sorry  Ask for help  No other option is not an indication to do a procedure  Optimal Femoral artery access  Pericardiocentesis  Do not treat nonischemic symptoms  Prevention of contrast nephropathy & bleeding  Talk to your patient before, during, & after catheterization read the c hart  Plan the case equipment environment support  Call a failure a failure Learn how to say I’m sorry  Ask for help  No other option is not an indication to do a procedure  Optimal Femoral artery access  Pericardiocentesis  Do not treat nonischemic symptoms  Prevention of contrast nephropathy & bleeding Preventing complications of diagnostic cardiac catheterization: some cognitive and philosophical issues, and a couple of critical techniques. In Complications in Percutaneous Interventions for Congenital and Structural Heart Disease, pages 321-336, 346-352, Informa, London, 2009.

21. “Everyone has a plan ‘til they get punched in the mouth.” Mike Tyson

22. Failure is a dress rehearsal for success.