Atul D. Bali, MD

Excited to share our paper, now out in @JACCJournals! Important work led by @MAlvarezVillela: 🔥 Fever in AMI-CS is common and is associated with greater illness severity but seems to be noninfectious in most cases #CardiogenicShock 🫀 doi.org/10.1016/j.jaca…

Key updates to this guideline include: ➡️ The use of the American Heart Association PREVENT-ASCVD equations to guide primary-prevention and lipid-lowering therapy decisions. ➡️ Testing Lp(a) at least once in a lifetime and selective apolipoprotein B measurement to improve risk assessment and guide treatment ➡️ The return of LDL-C and non-high-density lipoprotein cholesterol treatment goals (with lower targets for higher-risk groups) ➡️ Expanded use of coronary artery calcium scoring to reclassify risk[ME1.1] ✍🏼 @rblument1 @tygluckman @RonBlankstein @PamelaBMorris @pnatarajanmd @AnnMarieNavar @SethShayMartin @APRN_CNS @nyulangone @DrMichaelShapir @kgradneyrd @eugeniagianos @virani_md @KellieMcLain1 @ijeomaheartdoc @SamiaMoraMD @DrHeatherJohn @dmljmd

@AdityaMandawat DES for sure. Long term outcome with covered stent will be poor. DAPT - standard duration should be fine, after which I’ve done P2Y12 monotherapy over aspirin (which is becoming my standard as of late) Had a similar case a few months back:

How are folks dealing with lesions that involve an aneurysmal segment? DES or covered stent? Any changes to antiplatelet strategy? Anticoagulation?

2/ Piling on to finish the call weekend: Acute stent thrombosis of metal jacket LAD done a few days prior. With double layer in the prox SCAI D AMI cardiometabolic shock Multiple aspiration, repeated PTCA, distal vasodilators, MCS, lots of drugs Very tough thrombus burden

What a Christmas 🎄 call VT/electrical storm needing #ECMO Valvular #cardiogenicshock needing salvage BAV Mid LAD #STEMI w/ critical LM bifurcation disease Tamponade w/ hemorrhagic effusion & a CCU that has not let up, all during a snowstorm! Wouldn’t have it any other way 🙏🏽

@ISeropianMD @imedCV Apologies - I meant PCI prox-mid LAD, provisional across the diagonal, after focal stent in the mid diagonal

@ABaliMD @imedCV So you mean inverted provisional for the díag? LAD-Diag stent and FKB w/ diag & LAD

How would you great this 79 yo 👵🏻 su total LAD + Diag (huge) … it’s a pre #TAVI case from @imedCV ➡️ 2 stents upfront (DKC)? ➡️. Provisional witj bailoit TAP? ➡️. LAD distal to diag + diag ‘mail the ostium’ ?

4/ Procedural clips and IVUS post stenting (post dilation performed after) Will decide on RCA based on symptoms given cardiomyopathy.

3/ Ostial LM CSA - 3.2, severe dampening. 7Fr w/ SH, single access w/ tMCS Wiring was tricky! Took an XTA & was able to wire into a septal off the aneurysm, then direct down to LAD Up-front Rota 1.5 through LM -> mid LAD, IVUS sized DESx2 mid LAD to Ostial LM. (Bumper wire)

Last weeks complex case: 60s, dilated CDM (LV 6.8cm, EF 20%). P/w refractory angina, limited meds due to low BP on GDMT Not sick enough for transplant yet (ambulatory, CI 2.5, on oral 💊). Surgical turndown due to risk 🫀team➡️ PCI for QOL/angina How would you approach? #CHIP

2/ @evandrofilhobr @Laserrman @SripalBangalore @SaidAshrafMD @realarainmd @agtruesdell @DrRajeshG1 @MAlvarezVillela @PedroMDMSc @TWilsonMD @jl35wilsonMD @TanyaSh112 @SrihariNaiduMD @DrJayMohan @jaygirimd @GiorgioMedranda @mandeep_mayo @AkivaRosenzveig @HarisPatail

@SaidAshrafMD @evandrofilhobr @realarainmd @SripalBangalore @SrihariNaiduMD @LouaiRazzouk @AlkashkariWail @jaygirimd @agtruesdell @Babar_Basir Nice save! 🙌🏽 After that first shot of the next, would’ve immediately put in a CP, exactly as you did. Once stabilized, provisional PCI, swan & get out to CCU ASAP to correct hemos/metabolics. (Which will dictate survival).

Halloween Haunt: Male 60s with chest pain for 1 hour, EKG with STE in AVR & wide spread depressions. Hemodynamically stable ➡️ CCL ➡️ here’s what angio showed. After the second Left cors shot became acutely 🤢, hemodynamics collapsed hypotension + respiratory failure. What would you do next?

@flatspin000001 @brian_is_tired @PERTConsortium @InariMedical Apologies for the OP not being clear: this is an interventionaly approach to PE treatment - mechanical/suction thrombectomy using a large bore aspiration device @InariMedical. There are many available for use. Safety profile is excellent.

@brian_is_tired @ABaliMD @PERTConsortium @InariMedical Maybe thrombectomy in this context previously implied open / surgical thrombectomy. Nowadays, excellent thrombectomy options exist via catheters.

High risk PE on call last night🫀p/w syncope & ⬇️ BP Heavily impacted bilateral PE w/ saddle, RV/LV 1.6. Opening hemos c/w normotensive shock (on inotropes CI 1.4). MCS on standby. Immediate response to thrombectomy. POD1 - walking, normal RV fxn on TTE. #PERT @PERTConsortium

@Miazolam @Jonathan_PaulMD @PERTConsortium @InariMedical Unless its a true salvage situation, if there is a PE operator/cath lab available high-risk PE should be treated w/ intervention. Original data for lytics is shaky at best, w/⬆️ adverse events. Modern data for thrombectomy in HRPE is excellent both for mortality benefit & safety

@Jonathan_PaulMD @ABaliMD @PERTConsortium @InariMedical Is catheter-directed thrombolysis contraindicated in patients who remain unstable after systemic thrombolysis? Let’s say the closest ECMO center is hours away just for the example

@ISeropianMD @AntoniousAttall Patiently waiting 🙏🏽

@AntoniousAttall Does anybody now when results are going to be presented? I’m really looking forward for this trial, PEERLES II & PE-TRACT!!!! 🙏 Unfortunately STORM-PE doesn’t look as good (only 100 pt and RV/LV as EP)

congrats to all...along with #stormPE, this will be field defining. Hopefully an indication that we have been walking the right direction for the last decade...

@AlsaeediAlawiS @DrJayMohan @PERTConsortium @InariMedical @jaygirimd @GoldbergJBCTMD @AlsaeediAlawiS Difficult scenarios arise when there’s acute on chronic disease with baseline PH or RV dysfunction, exit strategies get complicated on MCS then. We’ve written about this before, as have many: onlinejcf.com/article/S1071-… @SrihariNaiduMD @MAlvarezVillela @TanyaSh112

@AlsaeediAlawiS @DrJayMohan @PERTConsortium @InariMedical I think the main scenarios 1) salvage hemodynamic state intra-procedurally, 2) actively coding/peri-arrest If the RV is well into its spiral, then hemodynamic stabilization w/ MCS should be considered first @jaygirimd and @GoldbergJBCTMD have given excellent talks on this

@jaygirimd @pritish_iyer @PERTConsortium @InariMedical 100% agree! Important data on the horizon. We enroll as many as possible at our center when we’re involved in studies, & our research coordinators do a great job assist in that at all hours. Still a challenge.

@ABaliMD @pritish_iyer @PERTConsortium @InariMedical Similar to MI and stroke, we need randomized data in this area to justify this practice. Good news is trials enrolling (with one complete). But important that all these patients get enrolled if presenting to trial sites as true risk/benefit is unknown.

This week we hosted the first edition of the Northwell Cardiogenic Shock Skills day. Over 50 junior faculty members and fellows from cardiology, IC, CTS & CCM joined a day of hemodynamic simulations, hands-on tMCS and PAC learning and expert discussions of real-life CS cases.

@pritish_iyer @PERTConsortium @InariMedical We base our strategy on evolving data. PE is following the same path is MI. 1st lytic era & now interventional era. Tricky part is the int-risk - innately low mortality, but rapid symptom relief is very important to pts, & long term prevention of CTED/PH? Questions remain still

@ABaliMD @PERTConsortium @InariMedical Very good to know. Thanks. Interesting to see institutional variability

@pritish_iyer @PERTConsortium @InariMedical Yes. If there’s evidence of RV strain on imaging, enzyme positivity, & symptoms either rest or exertional, we are intervening on intermediate risk PE routinely. Every PE is screened by our PERT pathway too and we have a rapid multidisciplinary discussion

@ABaliMD @PERTConsortium @InariMedical Are you guys performing thrombectomies/lysis on stable (but central) PEs?