72 year old NIDDM male with prior CABG (2012) and PCIs presented with CCS Class III angina, dyspnea and right leg claudication. A SPECT MPI revealed moderate inferior and inferolateral ischemia. A Cardiac Cath on May 3, 2018 revealed 3 V CAD, in-stent restenosis CTO of proximal RCA (distal vessel fills via LAD collaterals), 80% proximal LAD, 80% proximal LCx and 95% proximal Ramus with occluded SVG to RCA, to Ramus and to LCx-OM1, patent LIMA to LAD and LVEF 60%. Patient underwent successful intervention of proximal LCx using DES (Xience Alpine 3x12mm) and PTCA of Ramus. Patient still has CCS Class II symptoms on GDMT including three antianginals. Patient is now planned for recanalization of proximal RCA CTO in-stent restenosis via antegrade or retrograde approach followed by Rotational or Excimer laser atherectomy and DES implantation.
Moderator: Sameer Mehta, MD
Yes we were pleasantly surprised by the quick recanalization of the RCA CTO ISR which has been there since 2012 when pt had CABG and now the graft is occluded. It just needed Fielder guidewire to cross. We expected that much stiffer wires will be needed to cross but was rather it turned out to be an easy recanalization with just the Fielder wire.
Fielder (or Miraclebro 6) followed by Gaia-3 and then Confianza 12.
Fielder FC, Gaia-2 and then Confianza 9.
Antiplatelet therapy switch should be the part of new focused Interventional update to be published in late 2018 as has been suggested by the international consensus statement.
IV Congrelor is used in 1) acute PCIs with issues about absorption of antiplatelet therapy (hemodynamics compromise, intubated, elderly pts with swallowing difficulty taking pills lying down), 2) pt undergoing or underwent PCI and needs urgent non cardiac surgery prohibiting use of P2Y12 inhibitors; 3) lastly pt who had high risk PCI and needs unexpected noncardiac surgery within 1-3 moths of the PCI.
All cases of ELCA are done with saline flush to cause plaque vaporization except cases of unexpanded stents, where we use ELCA with contrast flush to cause explosion to break the Ca behind the stent struts.
There are only 2 ELCA catheters; 0.9 and 1.4 mm for the coronay use.
I believe case of TMVR was the best case of the CCVVC symposium 2018.
By far the monthly CCClive webcast has much higher educational value then annual CCVVC as supported by the audience of 8-10,000 hits per month and its global reach in 132+ countries. But just to be complete, CCVVC has its own brand educational value because of packed multiple variety of live cases with didactic debates and comments by the national and international faculty.
Yes starting July 2018, CCClive case will get 1.5-2 hrs CME credits to be given by the Icahn School of Medicine of MSH. Certainly it will require to go to the archived cases and answer 3 of the 5 questions correctly after watching the webcast.
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.