84 year old female with IDDM and prior CVA, presented with CCS Class IV angina after a small NSTEMI and had positive stress MPI with mild apical and anterior ischemia. A Cardiac Cath on January 2, 2018 revealed LM and 3V CAD: CTO of calcified proximal RCA, 70% distal left main bifurcation with 90% proximal LAD and 70% proximal LCx (Medina 1,1,1) and 80% mid LAD (Medina 1, 0,0) bifurcation with SYNTAX score of 41 and LVEF 50% due to inferopical hypokinesis. Patient underwent Heart Team discussion and CABG was declined due to advanced age and high STS score of 8.2. Patient is now planned for high risk PCI of unprotected LM bifurcation with dedicated two stent technique, IVUS guidance and possible LV support device.
Moderator: Sameer Mehta, MD
Of the two invasive imaging techniques, IVUS is a must in the Cath Lab and then OCT.
Yes, iFR data are solid and can be preferred in cases where adenosine can not be given for FFR (such asthma, AS). Hence all Cath Lab should have iFR capability. The Volcano’s machine can do both FFR and iFR with the same wire.
NIR is purely an investigational tool measuring Lipid core in the plaque and does not have long-term outcome data, hence not a must to have it in the Cath Lab; have ok only for research trials.
IVUS is essential and reliable for for measuring pre-procedure MLA and detection of calcium. It is also useful in CTOs to identify the ostium of the occluded vessel.
At present we have the most experience with BSC IVUS (iLab). Second is Volcano IVUS which has been integrated with Phillips Inc.
There has been proper reimbursement for OCT; always for the physician and for only ambulatory cases for the hospital. OCT reimbursement for inpatient is part of the DRG of the procedure.
There is nothing on the recent horizon but certainly will like to have a single catheter which can do IVUS/OCT and FFR/iFR. I am sure we will have this kind of catheter in our lifetime.
Just because it is simple and is being done with the wire and not with the over the wire catheter (then we used to remove the wire and connect catheter to the transducer; which used to be done in early PTCA days). Also now Pd/Pa data are simple and comparable to iFR data which is proprietary.
This is just like vascular closure devices which are being considered as the part of the procedure and is incorporated in the DRG and hence no separate reimbursement for the imaging procedures coupled with PCI.
Overall use of imaging during intervention can only go up if randomized trials will show their positive impact on clinical outcomes. Otherwise their use will remain in mid teens; currently 16% as per latest ACC-NCDR data in USA.
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.