Complex coronary cases
Staged PCI of Angulated LCx-OM1 Bifurcation Lesion with 2-Stent Strategy – Feb 2017

81 year-old male presented with new onset CCS Class III angina with positive stress echo for multi-vessel ischemia. A Cardiac Cath on December 2, 2016 revealed 3 V CAD: 70% proximal RCA with subtotal small RPDA; 90% proximal LAD, 100% D1, 80% proximal LCx with 95% angulated OM1 bifurcation lesion (Medina 1, 1, 1), SYNTAX score of 37 and normal systolic LV function. Patient underwent Heart Team discussion and elected for multi-vessel staged PCI. Patient underwent successful intervention of proximal LAD using Atherotomy and Promus Premier DES. He still has class II angina on MMT. Patient is now planned for staged PCI of angulated LCx-OM1 bifurcation lesion with dedicated two stent strategy.

2:39:39

Q&A
Q
What was the most key event in today's case that made it successful?
A.

Persistence despite various small setbacks and clear cut strategy of advancing the wire in the Diagonal distally beyond the dissection.


Q
How was today's patient sedated?
A.

Moderate sedation with periodic versed with local anesthesia.


Q
What would have been the options if you were unable to cross with the guide wire after it had been accidentally pulled out?
A.

Still continue other tricks like parallel wire technique and using more aggressive wires like confianza-9 and Gaia-3.


Q
What will be the DAPT strategy for this patient.
A.

Ticgrelor 90mg twice daily for 3 years due to complex interventions with aspirin 81mg daily.


Q
Stress test follow up or angiography - including evaluation of proximal RCA?
A.

Manage RCA medically and stress MPI in 9-12mths to detect any early restenosis even if asymotomatic.


Q
After transmission was ended, how was this case concluded?
A.

Just Proglide closure device of the FA and Pt shifted to CCU for overnight observation. Pt had no significant CK-MB elevation and was discharged home next day without any other events.


Q
If a patient has received a first generation DES, would you always have a longer duration of DAPT?
A.

I agree that pts with first generation DES because of poor healing, should get lifelong DAPT as long as tolerated.


Q
If another test validates findings for FUTURE, is it the end of FFR in interventional cardiology?
A.

Yes the results of the FUTURE trials are troublesome as well as the first of its kind. We need to wait for another FFR trial results like this. I still think that this trial results are an anomaly and interventional community is not putting too much emphasis or importance of this trial's results.


Q
Why do you think we had such disparity between FAME and FUTURE?
A.

The discrepancy between FAME vs FUTURE trials could simply be that in FAME, decision was made to do or not to do PCI based on FFR value of 0.8 while in the FUTURE trial overall decision of revascularization of MT, PCI or CABG was done based on FFR; that may not be appropriate. We know that in the ongoing FAME-3 trial of complex PCI, decision about CABG is being done based on the angiogram and not based on FFR, which is being used only in the PCI group. Hence in our ongoing clinical practice, we should use FFR to decide whether a lesion needs PCI or deferral of PCI.


Q
Would guidelines change as a result of FUTURE?
A.

I do not think that FUTURE trial will change the guidelines as there are numerous earlier trials of FFR which has validated its prognostic importance and has earned the spot in the guidelines as the Class I recommendation to do or not to do the PCI.


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One thought on “Staged PCI of Angulated LCx-OM1 Bifurcation Lesion with 2-Stent Strategy – Feb 2017”

  1. Dr Ajit V Kulkarni says:

    Sir, whats the approximate cost of such procedures? Is it possible in India to use so many wires


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