Intravascular Lithotripsy: additional tool to treat heavily calcified vessels

[ling]

Intravascular Lithotripsy: A New Atherectomy Option

acc.org/latest-in-cardiolog...

[Nathan53]

Thanks for posting Ling - a really interesting article. I have only heard of lithotripsy being used in a renal context but can see how it could have potential in cardiac field.

[Jimmy-45 in reply to Nathan53]

I had one performed on me towards the end of July 2019 on my proximal LAD. It was an elective procedure. It was far worse than the PCI during my MI 4 months prior.

They ran 8x 10 second pulses. Technically, I suffered a heart attack due to very elevated cardiac markers as the apparatus they used, blocked blood flow for 10 seconds each time for a total of 8 cycles, the maximum allowed.

It is really hard to describe but you can feel and hear pulses in your head like a crackle, an extremely painful crackle at that. In the chest, radiating through the throat/neck into the head. Excruciating is the word. Suffered through the next 24 hours after with angina like pains which was intense.

My wife thought I was exaggerating as the procedure during the MI did not elicit such pain. I was only released 72 hours after the op. The first 2 weeks after the elective procedure was hell. Had residual angina like pains which provoked anxiety at a debilitating level.

I'm now much better although I still have bad days. 2 questions still plaque me though. What happens to the fragmented calcium? Does it accumulate along the tail end of the artery? Also, I read that calcification is an evolutionary response to plaque. It prevents the plaque from rupturing. In such a context, should it not be left alone in lieu of the stent?

[Nathan53 in reply to Jimmy-45]

Yes I also wondered what happened to the fragmented calcium as the report makes no mention of that. I was scheduled for further elective PCI but decided against it when Cardiologist discussed the difficult area of blockage and the risk of rupturing an artery. I opted for conservative management via drug, diet and exercise. Your experience sounds scary hope you continue to improve

[ling in reply to Nathan53]

Nathan, is it ok to ask how u are doing on the "conservative management via drug, diet and exercise"?

Thank you

[Nathan53 in reply to Jimmy-45]

I found an article link att icrjournal.com/articles/cor...

which state that the calcium fragment after IVL remain in situ. I find the reports don't really explain things fully to a non medic or maybe I am just slow in understanding. Thought you may be interested though

[Jimmy-45 in reply to Nathan53]

Thanks. It was either a stent or a bypass. Chose the former given my age and I've been advised to go with stents till it is no longer an option. The bypass is a given although I'm trying to push it further out into the horizon. Fingers crossed for new techniques by then to sort this mess out.

[Nathan53 in reply to Jimmy-45]

I can fully understand you going down the least invasive route as you can always decide on a bypass at a later date. I had an Aunt who had a successful bypass in her 80's which was obviously a great challenge for her. She recovered well and within a year had a new lease if life. This as perhaps 25 years or so back when stents were not commonly used. All best Jimmy

[ling in reply to Jimmy-45]

Hi Jimmy, just wondering has the IVL worked out well, and has all pain from the procedure resolved?

Also, do you have any idea if the pain u experienced is a given for everyone undergoing the procedure?

Thank you very much.

[Jimmy-45 in reply to ling]

Hi Ling, just some background. Suffered an MI March 2019. PCI to the RCA. Left cath lab with multiple lesions with the most urgent being an 80% occlusion along the proximal LAD. Portuguese SNS decided on a wait and see max dose regime. Decided to scout around privately for a 2nd opinion.

Elected for a PCI vis a vis a CABG due to my age, which on 20/20 hindsight not not have been optimal.

[Jimmy-45 in reply to Jimmy-45]

They ran 8 cycles of 10 pulses. Each pulse was excruciatingly painful. You could hear/sense a crackle each time it pulsed. Cardiac markers and pain were elevated first couple of days. The pain eventually subsided. Felt weak for about a couple of weeks after due to reasons which is explained below.

Went for a routine cardiac MRI last year and discovered hypokinesis on the anterior/inferior wall ie the distal LAD. Damage was estimated at about 70% across the 3 layers of the cardiac muscle wall. Much more extensive damage than the MI which only showed a 15% damage on cardiac tissue. Ironic no doubt. It cannot be confirmed but the cardiologist conferred a high probability to the elective PCI which provoked my 2nd MI on the operating table. Apparently, during the PCI, the guidewire had to be inserted along the whole length of the LAD for the IVL which cascaded into an MI for reasons explained to me but I can't seem to recall.

The irony is that despite this 2nd peri-op MI, my EF is about 60% and global function is still considered good. This is purely my experience and it may not apply to all. Data is somewhat limited as it is still pretty new.

[ling in reply to Jimmy-45]

Thanks. The procedure sounds like one which causes a lot of pain compared to a regular PCI

[Jimmy-45 in reply to Jimmy-45]

Apologies for the long post. Just some additional notes. The IVL was used to soften the calcification in order to enable the stent to open up and adhere properly as opposed to traditional atherecromy.

Now, food for thought and it is obviously just my opinion. Calcification is a body's defense against MI? It lays calcium down and this prevents the plaque from rupturing especially 'hot' plaque which is the most common trigger of an MI? The benefit of 'decalcifying' as far as I see it, is for the stenting process itself.

[ling in reply to Jimmy-45]

If this theory is right, doesn't it mean that something as disruptive as the IVL during the decalcifying, could trigger a heart attack? Did the doctor warn of this before the procedure?

[Jimmy-45 in reply to ling]

As with all kinds of ops, I had to sign a waiver. No, it was not detailed out to me but I was advised that there were inherent risks.

That being said, the limited data shows a fairly positive safety profile. I think I have a perpetual black cloud shadowing me....

[ling in reply to Jimmy-45]

Sorry ... black cloud?

[Jimmy-45 in reply to ling]

Bad luck...

[ling in reply to Jimmy-45]

Many thanks for your reply.

This "PCI vis a vis a CABG", that's the IVL? It didn't work out as well?

[Jimmy-45 in reply to ling]

The elective PCI ie the 2nd stent was performed with the IVL. Opted for this because a bypass was deemed too early for me I will eventually need it further down the road.

[ling in reply to Jimmy-45]

Was the need for an IVL in the second PCI, identified from the first PCI?

[Jimmy-45 in reply to ling]

I suffered an MI to the RCA in March 2019. Other lesions were identified but the cardiologist under the public system was adamant that I can be managed with meds until the need for more invasive procedures shows itself which to me is not a solution as I cannot sit around waiting for the next MI to occur lest it is fatal.

So I went for a second opinion and was told it was a solitely necessary to get something done within the next 6 months to which I was offered a bypass by a cardiacthoracic surgeon or a PCI by an interventionalist. Opted for the latter after an agonizing decision and then did an angiogram in June 2020 to study the coronary arteries and a month later, had the PCI so yes, the 2nd stent was planned with the IVL in view of the calcification identified from the angiogram prior but not from the first stent.

That being said, it's important who you ask because from my experience, the cardiologist, surgeon and interventionalist are all vying for the same territory and at times they might not all agree.

[ling in reply to Jimmy-45]

Thank you very much.

On hindsight, was the second PCI absolutely necessary?

[Jimmy-45 in reply to ling]

To be completely honest, we will never know. I could have another MI and given that it's the LAD, it might be fatal. Even with the stent, another MI might still occur in the same spot due to restenosis. It is what it is. That being said, the 2nd stent has been an insurance and with insurance, you pay upfront to avoid a bigger problem down the road.

[ling in reply to Jimmy-45]

Would it be ok to share about your MI?

What caused your blockages?

[Jimmy-45 in reply to ling]

Diet and genetics, I believe, caused the CAD, nothing out of the ordinary here, even though I was within my BMI. No alcohol and never smoked. Just extremely elevated cholesterol.

Exercise, my cardiologist said, most probably triggered the MI. I was doing high intensity calisthenics for about 3 hours per day, 7 days straight with cold showers after. That raised the BP and BPM which might have caused a rupture in the plaque which cascaded into an MI.

Or maybe just old fashioned bad luck but at least I'm aware of the situation and can therefore take steps to mitigate the effects of the disease.

[ling in reply to Jimmy-45]

Did u know u had very high cholesterol before the MI?

I like the positive sound of that last para. What meds are u on?

It sounds like aside from the MI, your general body condition is good from all the exercise u did.

[Jimmy-45 in reply to ling]

My mum died a year prior to my MI at 69 due to a hypertensive MI. Had blood work done after which showed extremely elevated cholesterol levels. So in effect, I knew I had high cholesterol but not CAD.

My meds are the usual cocktail; PPI, aspirin, rosuvastatin and ezetimibe, lisinopril and ivabradine instead of a beta blocker because I have asthma. Stopped ticagrelor a year after my 2nd stent.

[ling in reply to Jimmy-45]

Sorry to hear that.

Is it Familial hypercholesterolemia?

[Jimmy-45 in reply to ling]

Possibly. Never got tested for FH. Has been difficult trying to keep my levels down despite a strict diet of legumes and sometimes oily fish. That's why I'm on 2 types of cholesterol lowering drugs.

Just under the PCSK9 inhibitors prescription parameters. It's a cost thing with the Portuguese SNS.

[ling in reply to Jimmy-45]

Really sorry to hear that.

I think the PCSK9 inhibitor could be really helpful.

I would also like to thank u, from the bottom of my heart, for taking the time to share your experiences. It's been an eye opener, and a great learning experience. I am most grateful.

[Jimmy-45 in reply to ling]

No worries. I've also learnt a lot on here. To better health for all.

[ling in reply to Jimmy-45]

MI to RCA. Does that mean the RCA had blockage?

Re the second PCI and 20/20 hindsight, do u mean a bypass would have been more effective?

[Jimmy-45 in reply to ling]

The RCA was blocked because of the MI, presumably because of plaque rupture cascading to blood clots. As to the degree of occlusion prior to the MI I have no idea.

However, I believe that small atherosclerotic plaque especially new ones are prone to rupture as their fibrous cap have yet to harden and stabilise.

Heart attacks are blockages preventing blood flow through the coronary arteries, causing irreversible damage to the heart. These blockages can come either from a plaque rupture or through aterial occlusion although, the former is more prevalent in MIs. The latter usually shows up as angina before developing into something more sinister.

[ling in reply to Jimmy-45]

Thanks for the information.

Can medication reduce arterial occlusion?

Does angina always deteriorate into something worse?

[ling in reply to Jimmy-45]

Dear Jimmy, just wanted to say thank you again. And to wish you all the best for your health.

God bless you!

Best wishes always.

[Jimmy-45 in reply to ling]

Thanks you for your kind wishes. Apologies for overlooking your prior post.The current consensus is that CAD is irreversible. The best we can hope for is to halt it's progression or slow it to a crawl.

That being said, there have been studies showing CAD regressing to some extent through aggressive LDL control either through statins or PCSK9 therapy.

There is also some anecdotal evidence of people reversing CAD through a strict diet regime.

There has also been studies that shows plaque reversal for plaque that has just been formed through strict cholesterol control although not for plaque that has advanced.

[ling in reply to Jimmy-45]

Thank you again.Didn't mean to trouble you further. Its been great being able to learn from your experiences. Thank you for the opportunity.

With best wishes.

[bantam12]

Heavens this sounds horrible, I had lithotripsy for kidney stones and it was the most painful procedure I have ever had in my life 😳 and it didn't work !