Q&A
Q.
Considering the LAD ostial and proximal segment lacked a robust MLA, would a 4.0 IVL have been better?
A.
Yes in hindsight, 4.0 IVL would have been better.
Q.
Or, a 2.0 burr?
A.
Agreed that a 2.0 mm Rota burr to begin with also would have been a better approach.
Q.
Larger stent?
A.
4mm stent was appropriate and then we did POT with a 4.5mm NCB at 20 atm; that was appropriate size.
Q.
More robust post stent dilatation with a non-compliant balloon?
A.
All stents can be further dilated for additional 1mm higher NCB and will still keep their physiological architecture. That exactly we did by using 4.5NCB at 20 ATM; IVUS showed adequate stent expression and apposition.
Q.
Aren't all recent STEMI trials attempting to discontinue Aspirin fundamentally flawed because they fail to inhibit the Thromboxane A2 pathway, which also seems important?
A.
That is correct that aspirin is essential in acute phase in STEMI pts and can’t be avoided fully. Hence 1-4 weeks of aspirin along with other P2Y12 inhibitor is a must in PPCI.
Q.
The concept, "IVL is the second burr," is very intriguing. Is this your strategy for ablating calcified lesions?
A.
I meant that after performing Rota with the initial selected Rota burr, in 10-15% of cases we used to need the second bigger burr. Traditionally it is well known that the bigger burr causes more heat generation, higher slow flow and CK-MB elevation and higher retinas (Stratus trial). Hence to avoid these added complications and to achieve adequate stent expansion in calcified lesions, IVL comes very handy to achieve the desired results; further calcium modification with minimal complications.
Q.
What is your rationale behind this strategy - offering two complementary ablative mechanisms while keeping costs contained?
A.
Another rationale behind Rota+IVL ( RotaTripsy) will be device synergy as described and is needed in about 20-25% of cases
Q.
In today's case, was this strategy optimal?
A.
Yes in today’s case Rota followed by IVL definitely gave us optimal stent expansion in our pt.
Q.
Is RotaTripsy the best ablative combination?
A.
Yes of all the combo strategies, RotaTripsy makes the best sense in severely calcified lesions.
Q.
Can Orbital Atherectomy substitute for Rotational Ablation? Cutting Balloon too?
A.
Cutting balloon+ IVL will provide only little additional synergistic benefit while OrbitTripsy can also be an option.
