Complex coronary cases
Rotablator and DES of Complex Calcified Ostial and Distal RCA Lesions – Dec 2011

86-year old female with prior DES PCI of mid LAD, presented with CCS Class IV angina. Cardiac cath on October 21, 2011 revealed 3V CAD and normal LV function and new culprit 90% lesion in distal LAD. Patient underwent PCI of distal LAD using Xience V DES. Now planned for Rotablator and DES of complex calcified ostial and distal RCA lesions.

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Q&A
Q
How useful is the flaring of ostial stent?
A.

Flaring of the ostial stent is very useful for ease of engagement post PCI or later if restenosis occurs. Otherwise stent deformation is likely to occur during attempting the guide catheter engagement.


Q
What is your strategy for managing the dissections extending into aorta while doing RCA ostial plasty- and what is the outcome of these?
A.

Most of these dissections are benign and appears as staining of the arotic wall without any chest/back pain or hemodynamic instability. If it is a small dissection involving the aortic root and ostium, an ostial stent may suffice. But some extensive dissections amy need to go to CT OR for aortic root reapir or replacement.


Q
What is safe and maximal pressure of Flextome in this ostial RCA case?
A.

Flextome can and easily go upto 14-16atm without concerns of balloon rupture.


Q
Would you consider a transradial PCI to reduce AKI because of less bleeding?
A.

Answer simply will be NO on this ground because then tardeoff is, little more contrast volume in transradial cases and need for swith in 6-8% of cases; that will be more detrimental for AKI.


Q
Is there any merit in using extra support rota wire for these large burrs for the ostial lesion as there is hardly any guide support?
A.

YES. Rota Extrasupport guide wire is a good choice for ostial lesions with poor guide support. In routine ostial PCIs, Rota Floopywire is good enough.


Q
What is happening with the PCI and CTS volume at Mt. Sinai Hospital for 2011?
A.

We are placing a system process of Heart Team (comprising of a CT surgeon, Interventionalist and a Cardiologist) consultation for stable CAD pts with Syntax score >22. That likely will appropriately increase CABG volume at Sinai. In 2011, we performed 4723 PCIs and 316 isolated CABG at Sinai.


Q
Are you using any age cut-off for using DES?
A.

NO because many of our elderly pts in 80's and 90's are living active life and restenosis of the complex lesions after BMS is more troublesome to treat. Hence it is patient's overall medical health which come into determination of DES vs. BMS use.


Q
So far as reimbursement is concerned, when you do stage a PCI and balance it scientifically?
A.

Most of the data support stage PCI to be done after 30-days and that will go long way in synch with emerging policy of 30-day bundle payment for PCIs.


Q
What is more impactful for PCI volume at Mt. Sinai Hospital - rigid adherence to Appropriateness Criteria or use of FFR?
A.

Rigid adherence to Appropriateness use criteria (AUC) has been very impactful in our day-to-day operation and our random quality check of 10% PCI cases in past, has shown that for stable pts, Inappropriate use of PCI at Sinai was <3% vs reported 11-14% nationally. Now we actually have built in a process in our cath lab reporting system, which will alert an Interventionalists if pt is Inappropriate for PCI based on the guidelines and making them 'rethink' before proceeding for PCI.


Q
Do you think increased peripheral interventions and structure heart management will make up for decline in PCI volumes?
A.

Absolutely YES and that is where future growth is being targeted at our center and nationally.


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