1. How I deal with…and what to avoid… calcified disease Adam de Belder Sussex Cardiac Centre Brighton ACI 2009

2. Declaration of interests  I have received honoraria from Boston Scientific to help train cardiologists in rotational atherectomy.

3. Very narrowed/CTO  Fibrous  Fibrocalcific  Superficial calcium  Deep calcium

4. Principle of RA operation Differential Cutting  All diseased plaque is inelastic  High speed rotational ablation differentiates healthy elastic vessel wall from plaque  High speed rotational ablation preferentially cuts all types of plaque morphology

5. Principle of Operation Differential Cutting Elastic tissue is able to deflect out of the way Elastic tissue space Elastic tissue deflects Direction of motion Ü Diamond crystal Inelastic tissue is unable to deflect out of the way Inelastic tissue space Direction of motion Ü Diamond crystal Forceful mechanical breakdown of matter

6. post-PTCA procedurepost-Rotablator ® procedure

7. Case  63 journalist - NSTEMI

9. Small balloon

10. bigger balloon

11. Even bigger balloon

12. Another case…..

13. 4 balloons, the final one of which was a quantum at 26 atm

14. CRIKEY….!!

15. Non-obstructive dissection – rotablation?

19. 4 weeks later…..

21. Final result

22. Calcification – what to avoid  Do not use oversized balloons in native coronary arteries and inflate them to very high atmospheres in order to ‘crack the lesion’…  If a case needs to be treated by rotablation, decide at an early stage with conventional PCI and stop the case

23. Calcification – what to avoid  Inexperienced users have the highest complication rates - do not use rotablation occasionally – buddy up with an experienced colleague or pass the case on to a regular user of the technology  …sometimes, you have to swallow your pride and accept that there are some cases that balloons and stents can’t treat

24. Rotablation experience – Sussex Cardiac Centre  N =222  70% >70yrs, 25%>80yrs  Hypertension – 84%  Failure to cross or poor result – 6.7%  Successful result – 93.3%  Complications – death n=2, QWMI n=1, dissection n=4, perforation n=3, tamponade n=1

25. Case – understanding calcium  55 yrs  Stable angina  Prox LAD  Previous pci severe dog-boning

34. Once you are confident with what can be achieved with RA, higher risk cases can be undertaken  87 yrs  Hb 9  Creat 400  Too high risk for surgery  Intractable angina

42. Conclusions  Understand the nature of the heavily calcified coronary artery  Understand the limitations and potential harm POBA and stenting can do  Do some IVUS and see what you’re dealing with  Learn/refresh how to rotablate with a proctor  Rotablation is not without risk – understand potential complications and how to avoid them  Frequent users have better results and are more confident with its capability  If you think the case requires a rotablation facility, then it probably does.. ..perhaps the laser?