Complex coronary cases
OCT Guided Staged PCI of ULM and LAD with Impella Assist for LV Support – August 2014

59 year-old male with prior BMS PCI in 1/2003, now presented with CCS Class II angina and high risk stress MPI for moderate to severe ischemia in 3 vessel distribution and severe dilated LV with TID. A Cardiac Cath on August 5, 2014 revealed II vessel + LM CAD with severe LV systolic dysfunction (LVEF 28%); CTO distal RCA, 70% distal left main, 80% ulcerated in-stent restenotic lesion in mid LAD and 70% D2 with SYNTAX Score of 34. Heart Team consultation was done and CABG declined strongly by the patient’s preference. Patient underwent successful PTCA and DES to distal RCA and RPDA without any complications. Patient is now planned for OCT guided staged PCI of ULM and LAD with Impella assist for LV support.

1:04:17

Q&A
Q
If this patient was your brother, would you dissuade him from PCI?
A.

We exactly did what I will do for my brother, that is have the consultation with the CT surgeon after strongly recommending CABG. If pt (or my brother) still wants to proceed for PCI, will proceed as the pt's wishes.


Q
If I was doing this patient in my hospital in Florida, they would take my PCI privileges away. How do you respond to this apprehension?
A.

At present having a Heart team discussion and then proceeding after the team recommendations will protect everyone and is in line with the ACC/AHA guidelines.


Q
Great demonstration of OCT to demonstrate lesion morphology? Are you using OCT more for this purpose and for identifying TFCA?
A.

Fully agree that OCT provides great visualization of TFCA. We are using OCT more as the part of the research tool.


Q
In UPLMCA, if the LCX ostium has zero disease, will you almost always, stent across the LMCA, and not bother wiring it either?
A.

Over the years, approach of stent crossover has changed with current generation DES because of extremely low side branch closure post stenting. Hence stenting across the circumflex without wiring the circumflex is routinely being done.


Q
Final kissing only if there are two stents, of course?
A.

Final kissing inflation (FKI) is done is sidebrabch has compromised flow after one stent and of course in all cases after two stent technique.


Q
f the interventional cardiologist is not present in the Heart Team discussion, then a valuable input is missing?
A.

I believe that it is the CT surgeon who is essential and more important then the Interventionalist.


Q
Always platelet testing for Unprotected LMCA treatment?
A.

I recommend Prasugrel or Ticagrelor as the preferred antiplatelet therapy along with aspirin and no need for platelet testing. Yes if clopidogrel is used with 2 stents, then PRU testing should be done. Cases of simple one LM stent, platelet testing is not necessary.


Q
What should be the ideal amount of dye to be used for OCT injection? Are there ways to minimize or the recommended dye injection volume is mandatory?
A.

That is the limitation of current OCT that it requires 10-12 cc bolus of contrast injection. May be future OCT devices will minimize that amount.


Q
What practical tips do you have for injecting, non-ACIST, for OCT analysis?
A.

Just the forceful manual injection of 10 cc of dye with guide catheter engaged in the coronary ostium.


Q
What additional data will be needed to make OCT an essential PCI tool?
A.

Outcomes data incorporating OCT will be required before it can be incorporated as the essential imaging tool with PCI. Currently one third of the insurances, do not even reimburse for OCT while there is no issue of reimbursement with IVUS.


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