Talking With the Operator

Interview With Bernardo Cortese, MD, FESC, FSCAI

© 2025 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Cath Lab Digest or HMP Global, their employees, and affiliates. 

Bernardo Cortese, MD, FESC, FSCAI
Interventional Director of the Coronary Center, University Hospitals Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio

Read the case discussed by Dr. Cortese here: 
Complex High Risk Percutaneous Coronary Intervention in a 54-Year-Old Patient After Surgical Turndown and a Unique Approach to the Heart Team

Tell us about this case.

This was a complex intervention requiring quick decision-making that centered around a heart team approach. The patient was referred by another hospital outside of our system, where he was admitted for an acute coronary syndrome and underwent urgent coronary angiography which showed severe left main trunk stenosis. Since they were not able to admit him in the main campus of the other system, he was then sent to our main campus at University Hospitals for cardiac surgery. It was a Sunday morning and the attending physician from the cardiac interventional care unit (CICU) called me, the cardiac surgeon, and my fellow. We reviewed the images with the Epic Haiku app, had a heart team discussion online, and planned an urgent percutaneous coronary intervention (PCI) after canceling the possibility of a cardiac surgery due to comorbidities. In the secondary hospital, the patient experienced cardiac arrest, so we had a neurological consult and waited a few hours for the patient to recover neurologically. The PCI was then done with a good result, with the balloon pump remaining in place until the next day.

Why was surgery not an option? 

It was an angioplasty for diffuse disease of the left main trunk, which is usually refused by the vast majority of interventional cardiologists due to the high risk of complications, and thus managed by the cardiac surgeon. However, this patient had a history of cancer despite his young age. The patient had cancer 22 years ago, but since he had undergone radiotherapy, that was an exclusion criterion for our cardiac surgeon.

What is challenging about dealing with left main disease? 

You can see from the images in this case that the left main had a 99% stenosis. The risk is that when you cross with a wire, the vessel can close, leading to cardiac arrest. If we had an occlusion of the left main, an external pump helps to sustain the heart for those seconds where we would need to dilate the lesion. This patient had already experienced two episodes of cardiac arrest while at the secondary hospital and that is also why we did this intervention with the support of a balloon pump. 

In the University Hospitals system, we have 36 interventional cardiologists. Only few treat the left main, but a 99% stenosis of the left main is immediately considered for cardiac surgery, without question. Nobody would consider treating this percutaneously as a matter of course. In our case, the cardiac surgeon did not want to operate on our patient, which was a significant issue because this was a young patient, 45 years old. 

How did you approach the left main stenosis? 

First, we needed a guiding catheter that was not too aggressive. You don’t want to touch the left main because of the risk for an acute occlusion, and the wire needs to be very delicately manipulated. After the first wire, the other branch needed protection, so a second wire was placed. Next, we wanted to do intravascular ultrasound (IVUS) and predilated gently without cracking the vessel in order to pass the probe of the intravascular imaging catheter. IVUS showed the lesion was calcific. Here, we used a cutting balloon. Due to the urgency, we didn't have the time to perform other types of calcium modification. In our experience in this setting, rotablation, orbital atherectomy, or intravascular lithotripsy (IVL) would have been too risky. For IVL, you have to keep the balloon inflated for a long time and we could not afford that with this patient. We needed to be fast, which is why we used a cutting balloon, because you inflate and deflate immediately. We did another predilatation, obtained a good result, and then implanted the stent. 

How is the patient?

We saw our patient at the end of last year. He was very happy and wanted to come back to work. He underwent a brief period of rehabilitation and is completely functional. 

What are the characteristics that indicate you are facing a complex, high-risk PCI? 

Complex patients are referred to by the acronym CHIP (complex and high-risk interventional procedures). This includes patients with cancer, at high bleeding risk or with ongoing bleeding, patients with diffuse disease, peripheral disease, a porcelain aorta, patients with a previous stroke, those with renal failure, and patients with liver failure. The other aspect is technical. There are several patterns that classify a patient under high-risk PCI from a lesion standpoint, among those being left main involvement. The complex lesion setting also includes severe calcified lesions, chronic total occlusions (CTO), and complex bifurcations also outside of the left main. 

Do you have any advice for interventionalists?  

First, you have to be highly skilled to deal with these patients. You cannot just apply a flow chart. You need clear ideas, must already know options A, B, C, and D (whatever they might be), and need to anticipate the next step in advance. Second, these patients can deteriorate immediately, so you must work fast. Don’t delay because you want to get a different image, for example. Third, you have to be conservative with contrast administration because in a patient with a 99% stenosis, using too much contrast dye can be ischemic and further deteriorate ventricular function. Finally, you need protection for the heart from mechanical circulatory support, as with the balloon pump in our case, or with Impella (Abiomed), which is being used in many CHIP patients.

About Dr. Cortese

Bernardo Cortese, MD, FESC, FSCAI, is a highly experienced clinician and avid physician researcher from Italy who will be furthering University Hospitals (UH) Harrington Heart & Vascular Institute’s mission to provide the highest quality coronary care across 18 locations in Northeast Ohio.

Dr. Cortese comes to UH from Milan, Italy where he has served as Director of Cardiology of San Carlo Clinic and as a consultant interventional cardiologist for coronary and structural heart disease at Columbus Clinic and Fatebenefratelli Hospital.

He has been a leading investigator on more than 60 clinical trials for novel cardiovascular therapies and techniques. Dr. Cortese has more than 370 articles in peer-reviewed medical journals. He also serves as reviewer and editorial board member for multiple international journals. As a respected educator, he has active proctorships in complex coronary artery disease percutaneous coronary interventions in Brazil, throughout Europe, from Austria and Spain to Poland, Croatia and the Czech Republic, and across Asia, from Bangladesh and Thailand to Malaysia and Singapore. He is President of Fondazione RIC (www.fondazioneric.org), a scientific organization, and of DCB Academy, an international Fellowship program.

Read the case discussed by Dr. Cortese here: 
Complex High Risk Percutaneous Coronary Intervention in a 54-Year-Old Patient After Surgical Turndown and a Unique Approach to the Heart Team