Ivl basics

Coronary Intravascular lithotripsy, IVL, sonic waves, basic steps, how to use

1. CORONARY INTRAVASCULAR LITHOTRIPSY -ROHIT WALSE FELLOW INTERVENTIONAL CARDIOLOGY SCTIMST, KERALA

2. SCOPE INTRODUCTION LIMITATION OF CURRENT ATHERECTOMY LITHOTRIPSY-MECHA, HARDWARE, STEPS DATA

3. INTRODUCTION Coronary artery calcium - independent predictor of worse prognosis TRIALS f/u Outcome Bourantas et al, 2014 BMJ 3 yr High mortality (10.8 vs 4.4) [p <0.01] Lower rates of complete revascularization HORIZONS-AMI 1 yr  Rates of complications  Stent underexpansion ACUITY CORONARY CALCIUM

4. Heavily calcified vessel by OCT Arc >180 Length > 5 mm Thickness > 0.5 mm

5. Predictable problem during vessel preparation High pressure balloon dilatation Constant High pressure Violates intima of vessel Inflammation, Smooth muscle proliferation Scar Less effective Intervention

6. Limitation of current atherectomy Selectively ablates superficial calcium Incomplete or asymmetric stent expansion  acute or subacute stent failure

7. LITHOTRIPSY [ Litho -stone; tripsy -break] 30 yrs safety data in kidney stone treatment

8. After inflating the integrated balloon to 4-atm, a small spark at the emitters vaporizes the saline-contrast solution and creates a bubble which rapidly expands and collapses within the balloon; this expanding and collapsing bubble creates a short burst of sonic pressure waves. The sonic pressure waves travel through the coronary tissue, while reflecting off and cracking calcium with an effective pressure of ~50 atm . The emitters along the length of the device create a localized field effect within the vessel to fracture both superficial and deep calcium

9. MECHANISM Impact hard tissue Disrupts calcium Soft tissue No harm Sonic pressure waves

10. IVL TECHNOLOGY Miniaturized & arrayed lithotripsy emitters for localised lithotripsy at the site of vascular calcium Optimized for treatment of vascular calcium

11. HARDWARE

12. Steps of use Identify the lesion & predilate as necessary Select IVL balloon catheter size- 1:1 Load the catheter, position the balloon within target lesion

13. Inflate balloon @ 4 atm with saline contrast[60:40] & deliver treatment sequence (1 cycle-10 pulses over 10 sec) {Total- 80 pulses} Inflate the balloon upto 6 atm till cool down phase Repeat as necessary, deflating the balloon between treatments to re establish flow

14. PRACTICAL POINTS Concentric lesions- 2-3 cycles Eccentric lesions- 3-4 cycles Long lesion- Distal to proximal Calcific spikes- 1-2 cycles ( upto 4 atm ) n then during 3-4 th cycle upto 6 atm

15. Advantages of IVL in LM ds Safely Modifies Calcium with Low Risk of Perforation Ability to Have Buddy Wire in Place While Modifying Calcium Can Modify Calcium in Large Vessels Not Ideal for Rotational Atherectomy (RA) Ability to Impact Deeper, Medial Calcium

16. Advantages in bifurcation lesion Ability to Navigate Tortuous Anatomy Can Keep Multiple Wires Down While Modifying Calcium Circumferential Calcium Modification Without Wire Bias Low Risk of Dissection

17. EFFECT ON CARDIAC RHTYHM Acoustic shock waves Localised myocardial depolarization APCs or VPCs ( Shocktopics ) [No VT induced by IVL has been so far reported]

18. THANK YOU