Atul D. Bali, MD

Interventional Cardiologist @lenoxhill / @ZuckerSoM🫀| Interests #CHIP #PERT #CardiacCriticalCare | Previously @nymedcollege @PennMedicine | tweets are my own |

[Atul D. Bali, MD @ABaliMD]

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 🫀

https://t.co/d13b93sEhx

[Atul D. Bali, MD @ABaliMD]

Very interesting from @GreggWStone

Makes sense intuitively - more ischemic time on an already stunned myocardium, elevating EDP, contrast delivery etc...

Non-shock doesn't necessarily mean patient is "stable".

[Gregg W. Stone MD @GreggWStone]

Complete revasc (CR) in pts with non-shock STEMI and multivessel ds. reduces MACE. But is the best timing for non-culprit lsn PCI immediate (during primary PCI) or staged? Our new meta-analysis publ in Circ CV Interv suggests immediate CR may increase mortality, same as in shock.

[Atul D. Bali, MD @ABaliMD]

@SaidAshrafMD Prob eruptive nodule w/ thrombus, TIMI 3 is reassuring. (IABP & bring back also reasonable)

Would’ve wired that 📐 w/ 120 SC, tried 🎈(NC/Cut/IVL) first for atherotomy as primary Ca mod. OCT here.

Limit atherectomy w/ eruptive nodules to avoid no reflow, but Rota 1.5 if needed

[AHA Science @AHAScience]

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

[Atul D. Bali, MD @ABaliMD]

@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:

[Atul D. Bali, MD @ABaliMD]

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

[Atul D. Bali, MD @ABaliMD]

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 🙏🏽

[Atul D. Bali, MD @ABaliMD]

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

[Atul D. Bali, MD @ABaliMD]

4/

Procedural clips and IVUS post stenting (post dilation performed after)

Will decide on RCA based on symptoms given cardiomyopathy.

[Atul D. Bali, MD @ABaliMD]

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

[Atul D. Bali, MD @ABaliMD]

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)

[Atul D. Bali, MD @ABaliMD]

2/

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

[Atul D. Bali, MD @ABaliMD]

@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).

[Atul D. Bali, MD @ABaliMD]

@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.

[Atul D. Bali, MD @ABaliMD]

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

[Atul D. Bali, MD @ABaliMD]

@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

[Atul D. Bali, MD @ABaliMD]

@ISeropianMD @AntoniousAttall Patiently waiting 🙏🏽

[Atul D. Bali, MD @ABaliMD]

@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:

https://t.co/E8WbV6xzjL

@SrihariNaiduMD @MAlvarezVillela @TanyaSh112

[Atul D. Bali, MD @ABaliMD]

@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

[Atul D. Bali, MD @ABaliMD]

@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.

[Miguel Alvarez Villela @MAlvarezVillela]

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.