Complex PCI of LAD CTO and Diagonal System – Dec 2014

70 year-old diabetic male with new onset angina, CCS Class I and strongly positive MPI for large anterior wall ischemia and transient ischemic LV dilatation. A Cardiac Cath at outside hospital on October 8, 2014 revealed 1V CAD; calcified CTO of mid LAD and severe stenosis of D2 with non-obstructive circumflex and RCA and LVEF 55%; SYNTAX Score 18. Mid LAD is totally occluded and fills via bridge collaterals and via retrograde collaterals from diagonal. In view of complex calcified lesions CABG was recommended, but patient declined and opted for complex PCI. Patient is now planned for complex PCI of LAD CTO and Diagonal System.



Q What are your overall views on the DAPT study by Dr. Mauri?
A. The DAPT study provided 2 important messages; 1) That benefit of extended DAPT is mediated by both reduction in spontaneous MI as well as SAT (1% each) and 2) Prolonged DAPT will cause more bleeding and perhaps higher mortality. Hence decision about prolonged DAPT needs to individualized; straight forward simple DES case or pt with bleeding predisposition should get short 6-12M DAPT and pts with frequent CAD manifestation, post MI and multiple stents should get prolonged DAPT.
Q What are the most solid contributions of this trial?
A. Most important message from the DAPT study was that there is certainly a benefit of prolonged DAPT in pts with extensive CAD with frequent occurrence of symptoms as for secondary prevention (similar to Charisma Trial).
Q Are there some areas that have become hazy?
A. YES as proponents of prolonged DAPT will recommend it for majority of PCI cases, which is contrary to numerous other randomized trials which has attested to safety and efficacy of the of short DAPT (3-6mths).
Q Where do we go from here regarding DAPT, post PCI?
A. As explained above, this field of DAPT duration has really created much controversy now and there will be conflicting opinions. But in my opinion, in majority of pts we do not need to change our practice of 1 year DAPT post DES PCI.
Q Can we expect change in guidelines?
A. I do not believe that DAPT will change the guidelines because while there was benefit of prolonged DAPT, it also had higher bleeding and mortality.
Q Or practice patterns?
A. We should continue what is our current practice; majority of DES PCI pts should get DAPT for 1 year, some straight forward uneventful PCI cases high risk for bleeding should get DAPT for 6 mths and some frequent CAD manifestation cases should get prolonged DAPT for 3 yrs.
Q Does BVS get affected by changing DAPT use patterns?
A. Actually what we know now with the DES SAT data, I will not recommend any change for DAPT with BVS which has shown higher SAT compared to metal DES.
Q What is your plan for the CTO case for today?
A. Interventional plan for distal LAD CTO was to use the wire escalation technique to re-canalize the CTO and then may do atherectomy before stenting. We now know that all our strategies failed in this CTO case and we were unsuccessful.
Q Should one provide a blanket success rate of about 80% for CTO to patients and relatives or make a case by case recommendation - that may have been 50-60% for the case you performed, and further clearly qualify about the need to return for a staged CTO intervention?
A. Yes when we state 80% success rate to the pt, we do emphasize that in some cases there will be a need to come back for second staged procedure in some cases (about 15-20%).
Q Would you have done anything different if you were doing this case again?
A. Only different approach will be to use Confianza-9 wire earlier then later and will make it as the first wire to cross the lesion after delivery of Finecross to the lesion over the Fielder wire.


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