64 year old male presented with new onset CCS Class II angina and a positive stress MPI for anterior, apical and septal ischemia. A Cardiac Cath on November 7, 2017 revealed II Vessel CAD: proximal LAD CTO bifurcation (Medina 1,1,1), with 80% D1 bifurcation, 70% LCx-OM2 with a SYNTAX score of 30.5 and LVEF = 60%. Patient underwent FFR of the LCx, which was 0.91 (-). Patient is now planned for staged PCI of LAD CTO-D1 bifurcation with planned 2-stent technique.
Moderator: Sameer Mehta, MD
I agree that we should have 6month followup of the ORBITA trial because pts with +FFR had higher events of urgent revascularization at 5-7 months followup which led to premature termination of FAME II trial.
I predict that many pts in the Sham PCI group on their own request or recommendation by their treating cardiologist will undergo PCI after 2 months when they were told that they did not have actual PCI.
I think it is already an old news as it did not have the fallout of PCI as we had after COURAGE trial. I still think that some insurance companies may mandate approval of Cath only first and then MMT and will approve PCI only if MMT fails as the second step/stage.
Yes a simple message is that, PCI in single vessel CAD should only be done for symptoms of persistent angina, exercise limitation or ischemia on stress testing on MMT.
I strongly believe that some of the insurance companies start approving coronary angio only and then maximize the Medical therapy (MT). If MT fails then only PCI will be approved. Or simply insurance companies should start mandating FFR measurements before elective PCI for stable pts; that PCI only if lesion has FFR of <0.81. This will be the right thing to do supported by various RCTs.
Dedicated 2 stent technique is better then provision stenting for LM bifurcation lesions. Preferred Type of 2 stent technique will vary based on the personal experience. Data have shown DK Crush as the preferred approach but requires multiple steps and others like Minicrush or Culotte are relatively simple and are also expected to give similar results. We routinely do Minicrush for distal LM bifurcation with excellent short and long term results (case # 100 was Minicrush for dLM bifurcation).
Average wire passage time for antegrade CTO wire recanalization at Mount Sinai is 22 minutes along with the mean total procedure time of 55 minutes. Average wire passage time for retrograde recanalization is 45 minutes.
We have 95% Antegrade (usually 2 attempts) and 5% Retrograde technique for CTO recanalization at MSH.
Bifurcaid App really is a great resource for a practicing interventionalist. It’s main utility will be to plan the case before the actual procedure. In rare situation, if case is not proceeding as planned, it will reasonable to go thru the trouble shoot steps from the App.
Three best trials from TCT which will change our Interventional thought process and strategies are Culprit Shock, ORBITA and DK-Crush V.
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.