COMPLEX CORONARY CASES
IVUS Guided Protected PCI – December 2017

88 year old female with prior BMS in proximal LAD in 2010, presented with worsening dyspnea on exertion (NYHA class III) and mild chest pressure for few months. A recent echo revealed a fall in LVEF from 55% in 2010 to 22% now. A Cardiac Cath on November 28, 2017 revealed heavily calcified II vessel and 80% Left main bifurcation disease involving proximal LAD (patent BMS) and ostial circumflex, SYNTAX score of 24 and LVEF 26%. IVUS revealed distal LM MLA of 5.2 mm2 with significant prox LAD and moderate ostial circumflex disease. Patient was optimized on heart failure and anti-ischemic medical therapy. A stress thallium MPI on November 30, 2017 revealed global ischemia and viability in anterior, inferior and lateral walls. Patient is now planned for IVUS guided Protected PCI of ULM bifurcation utilizing Rotational Atherectomy & Impella hemodynamics support and dedicated 2-stent technique.

Moderator: Sameer Mehta, MD

1:00:28

Q&A
Q
What is the best way to use Bifurcaid App? Should one master it by plugging his/her individual case each time a bifurcation is encountered?
A.

The best way to use Bifurcaid App is to go thru it once with it’s all bifurcation type scenarios including home button items. It will take about 30-45 minutes. Once you have familiarize with the App, then it will be easier to plug in your bifurcation case in a particular bifurcation type scenario and get the true guidance by the App.


Q
Same way to advance learning curve by viewing during ccclivecases with bifurcation cases?
A.

Absolutely all the bifurcation steps done in the CCClive cases are the backbone of the Bifurcaid App. It not only highlights the meticulous technique but also provides the resource and line of action when trouble occurs.


Q
Do you plan upgrades to the app every few months as new data emerges and new hardware becomes available?
A.

We actually are in process of upgrading the Bifurcaid App by adding total 15 references and making minor changes. Yes in future, our goal is to make periodic updates based on the new informations.


Q
Is there any group of patients in your practice where you are using DAPT only for a month?
A.

There are some pts where we are using DAPT only for one month such as non-LM or non-bifurcation lesions who are planned for non-cardiac surgery in one month. Also pts with liver disease or platelet count between 50-100k, we tend to use either SAPT (clopidogrel) or DAPT for one month. Also high risk lesions PCI pts requiring OAC (warfarin or NOAC), routinely get DAPT for 1-3 mths and then changed to SAPT.


Q
For 3 months?
A.

Again pts with planned non-cardiac surgery and who are at high bleeding risk, are prescribed DAPT only for 3 months.


Q
And group of patients where you will definitely use 12 months DAPT?
A.

Many PCI pts will benefit from long DAPT (1-3yrs+) such as pts with multiple stents (>3), proximal bifurcation lesion requiring 2-stents, pts who had Stent Thrombosis after DAPT discontinuation and uncontrolled diabetes. In many of these scenario, benefit of prolonged DAPT is not only from reducing ST but also in reducing ACS from new lesion formation (non-stent related events).


Q
And permanently?
A.

Yes, many of these pts described above will benefit from long term DAPT as long as there are no bleeding issues.


Q
How many TRA did you personally need to master the technique?
A.

Literature supports a rapid learning curve to master the TRA technique; that # is 75 and complications goes down with lower failure (crossover) rates at 150+.


Q
Today, everything else being equal, with both options available, will you prefer femoral route?
A.

I personally believe the clear advantage of TRA over femoral approach in following scenario; STEMI, PAD, non-CABG pt, first time presenter, obese pts (weight >100kg), bleeding diathesis, thrombocytopenia and pts on OAC.


Q
Should we expect Class 1 indication for TRA for some indications?
A.

Just like 2016 ESC PCI update making TRA as Class 1 in STEMI pts, next focused PCI update of ACC/AHA will certainly make TRA as Class 1 in STEMI/ACS cases.


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