Uncategorized cases
Complex Multivessel PCI in a High SYNTAX Score Patient – October 2020

Case and Plan:

74-year-old obese male on HD presented with CCS Class II angina and positive SPECT MPI on July 14, 2020 done as pre-op for renal transplant revealing moderate apical, inferior and inferolateral ischemia. A Cardiac Cath on August 20, 2020 revealed 3 V CAD: 70% mid RCA, 100% RCA-AV Cont, subtotal calcified mid-distal LAD, 60% D1, 80% LCx-OM2, 80% LCx-LPL1, LVEF = 55% and SYNTAX Score of 33. Heart discussion followed and patient declined CABG. Patient is now planned for high risk multivessel PCI with appropriate use of IVUS, rotational atherectomy and Impella LV assist as needed.

Q&A
Q
Why is there a 6 month waiting post PCI for a transplant?
A.

Post DES PCI, while there are trials stoping DAPT at 1-3 M in high bleeding risk pts, but waiting for 6M (even 12M) before renal/liver transplant is routine and has not been studied further to abbreviate the DAPT duration. During transplant high doses of clotting agents are used to stop bleeding and many of anti-rejection therapies are pro-coagulant promoting thrombosis. Hence shorter then 6M DAPT duration post DES for transplant pts is not currently recommended.


Q
Is that specifically for renal transplantation?
A.

Actually 6M DAPT post DES is routine for both renal and liver transplantation. It is more problematic for renal pts, because many times are 6M, pts start developing restenosis (clinically or on MPI) and then needs repeat cath/PCI, pushing the potential transplant date further.


Q
When would you plan for the staged PCI for this patient?
A.

Today’s pt has been scheduled for staged PCI after 1M on Nov 20. That is our routine practice except in some cases where time interval is shortened to 1 or 2 weeks based on the severe unstable coronary lesions.


Q
Would the anti-platelet regimen be different for such patients?
A.

Antiplatelet therapy choice should depend on pts clinical scenario (stable vs acute) and lesion morphology (complex type c or non-C). Clopidogrel is still used in over 60-70% of all PCIs and numerous registry and trial data have now reassured us that, this practice is appropriate.


Q
In what cases would lithotripsy work?
A.

Lithotripsy (IVL) worked in 95% of selected cases in the Disrupt CAD III trial and required predilatation in 55%. Once clinically available and used in all comers, then only we will understand its true utility. Certainly IVL will be device to have in the cath lab because of simplicity of use and rapid learning curve.


Q
What would lithotripsy impact more - orbital atherectomy, rotablator or cutting balloon?
A.

In my opinion Lithotripsy (IVL) will significantly reduce our use of cutting balloon with little effect on atherectomy use. In my opinion, IVL will increase the total number of calcified lesions we are treating by lowering the interventional threshold by the usual operators.


Q
Of all CTO wires, are you finding the GAIA 3 wire most effective? Are you now moving to its use earlier in the CTO guidewire algorithm?
A.

Yes Gaia-3 is an excellent wire for CTO crossing and we have started to use it quickly after initial try with Fielder. Hence it's use is now at #2 in the CTO algorithm. If it fails, then we go to MiracleBro 6-9 or Confianza 9-12 guidewires.


Q
What is your perspective regarding BVS re-emergence following the Prospect trials?
A.

in my opinion, BVS resurgence is a long-way to come back for clinical use and PROSPECT-BVS is not going to change it. FDA will mandate clinical trials of BVS to have 3-year endpoint as trouble in the Absorb trials happened after 2-3 years. I am sure no company is ready to invest in this technology and wait for 3 year trial results.


Q
In what percentage of your cases, do you feel you achieve an FFR>0.90, post stenting?
A.

We do not routinely measure FFR post PCI and it seems from the Target FFR trial that routine measurement is unlikely to help in clinical decision or have any impact on subsequent MACE. Also it is very difficult to normalize FFR post-PCI to >0.9 despite various approach to correct it.


Q
Should one thrive for FFR>0.90 in every procedure?
A.

Based on the prospective data of Doctors trial and Target FFR trial, we should not thriving for FFR >0.9 post PCI as it is very difficult to achieve despite multiple efforts. I will suggest to use IVUS or OCT, if post-PCI lesion appears suboptimal on angiogram; imaging will give a better clue then FFR and problem identified can easily be corrected.


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