81 year-old male presented with new onset CCS Class III angina with positive stress echo for multi-vessel ischemia. A Cardiac Cath on December 2, 2016 revealed 3 V CAD: 70% proximal RCA with subtotal small RPDA; 90% proximal LAD, 100% D1, 80% proximal LCx with 95% angulated OM1 bifurcation lesion (Medina 1, 1, 1), SYNTAX score of 37 and normal systolic LV function. Patient underwent Heart Team discussion and elected for multi-vessel staged PCI. Patient underwent successful intervention of proximal LAD using Atherotomy and Promus Premier DES. He still has class II angina on MMT. Patient is now planned for staged PCI of angulated LCx-OM1 bifurcation lesion with dedicated two stent strategy.
Persistence despite various small setbacks and clear cut strategy of advancing the wire in the Diagonal distally beyond the dissection.
Moderate sedation with periodic versed with local anesthesia.
Still continue other tricks like parallel wire technique and using more aggressive wires like confianza-9 and Gaia-3.
Ticgrelor 90mg twice daily for 3 years due to complex interventions with aspirin 81mg daily.
Manage RCA medically and stress MPI in 9-12mths to detect any early restenosis even if asymotomatic.
Just Proglide closure device of the FA and Pt shifted to CCU for overnight observation. Pt had no significant CK-MB elevation and was discharged home next day without any other events.
I agree that pts with first generation DES because of poor healing, should get lifelong DAPT as long as tolerated.
Yes the results of the FUTURE trials are troublesome as well as the first of its kind. We need to wait for another FFR trial results like this. I still think that this trial results are an anomaly and interventional community is not putting too much emphasis or importance of this trial's results.
The discrepancy between FAME vs FUTURE trials could simply be that in FAME, decision was made to do or not to do PCI based on FFR value of 0.8 while in the FUTURE trial overall decision of revascularization of MT, PCI or CABG was done based on FFR; that may not be appropriate. We know that in the ongoing FAME-3 trial of complex PCI, decision about CABG is being done based on the angiogram and not based on FFR, which is being used only in the PCI group. Hence in our ongoing clinical practice, we should use FFR to decide whether a lesion needs PCI or deferral of PCI.
I do not think that FUTURE trial will change the guidelines as there are numerous earlier trials of FFR which has validated its prognostic importance and has earned the spot in the guidelines as the Class I recommendation to do or not to do the PCI.
86 year old female with chronic stable angina CCS Class II and positive MPI for two years being managed on medication.
62 year old male presented with CCS Class II angina and positive SPECT MPI for basal inferior and inferolateral moderate size area of ischemia and infarction.
53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017.
74 year old male with CKD Stage III presented with CCS Class II angina and positive stress MPI for moderate inferoapical ischemia.