Staged PCI of Calcified Multiple Lesions of Mid and Distal LAD – Feb 2015

 

60 year-old male NIDDM with new onset CCS Class II angina and high risk stress MPI for large apical and inferior ischemia with transient ischemic dilatation and EF of 40%. A Cardiac Cath on January 8, 2015 revealed II Vessel CAD; 90% moderately calcified mid-RCA, 90-95% moderate diffusely calcified multiple mid-LAD lesion and distal subtotal-total occlusion with moderate systolic LV dysfunction, LVEF 40% and SYNTAX Score 21. Patient underwent successful intervention of mid-RCA (Promus Premier DES). Patient is now planned for staged PCI of calcified multiple lesions of mid and distal LAD.

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Q&A

Q Please explain the reason why you performed PCI of RCA first. Is our practice a good one where we first try to do the harder lesion to preserve the surgical option?
A. The rationale for RCA PCI first was that it was a 95% short lesion while distal LAD lesion is diffuse subtotal and pt would not have been referred for ABG just for distal LAD as all other lesions were amenable to PCI.
Q Do you always use stiffer wires to cross CTO with use of a support catheter?
A. We start with the floppy wire first (like Fielder in this case) and then rapidly go to stiffer wire; choice being Miracle 6 or Confianza 9.
Q Which is your favorite support catheter?
A. Finecross is our workhorse support catheter and rarely 1.5mm OTW balloon. There is another support catheter of BSC called Threader which also has 1.2mm balloon a the tip. It is working well in limited cases we have used so far.
Q What will become the clinical scenario for using rSS?
A. In my opinion, especially in young pt if CTO or a difficult proximal lesion in a large vessel is likely to remain un-revascularized, then CABG should be preferred. These cases should be the part of the Heart team discussion.
Q Do you feel rSS will be routinely used for PCI?
A. I fully support the calculation of potential rSS in a complex MV PCI case and after discussion if t is felt that rSS will be >8, then PCI should be discouraged and CABG should be preferred.
Q Will surgeons begin to adopt it too?
A. I am sure they will buy into this rSS calculation protocol and will be the part of Heart team discussion.
Q Is your institution participating in the Coronary Sinus Reducing device?Do you perform Spinal Cord stimulation and Ganglionectomy?
A. To my knowledge, Coronary Sinus reduction device is not being used in USA at present and is awaiting FDA approval. Spinal cord stimulation is not done at our center and Lt Sympathetic Ganglionectomy was done in 2 pts 12 and 14 yrs ago at MSH.
Q Could CS Reducing devices replace maximal medical therapy as a therapeutic option for refractive angina?
A. Being invasive, CS Reducing device once approved, should always be a second line therapy indicated after failure of MMT in refractory angina pts.
Q Have you found EECP beneficial and for which patients do you recommend it? How many sessions appear appropriate?
A. EECP certainly benefits in reducing angina frequency after 6 weeks of treatment (35 sessions) and now can be repeated every year as per latest guidelines.It is appropriate for refractory angina pts with no treatable epicardial disease and is likely due to diffuse small vessel disease.
Q How much would you expect the restenosis rate for the LAD procedure performed today?
A. Our case today needed 2 DES (2.5 and 2.75mm size and 32 mm length) and expected clinical DES ISR will be 8-10%. Usually DES ISR is focal and will respond to scoring balloon.

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