High-Risk Impella-Assisted PCI of Calcified LM Bifurcation – July 2022

Case and Plan:
78-year-old male with liver cirrhosis presented with exertional dyspnea and positive stress MPI test for multivessel ischemia. A Cardiac Cath @ OSH on May 24, 2022 revealed calcified 3 V + LM CAD: 80% dLM, 70% LAD-D2, 80% LCx, 95% proximal RCA and SYNTAX Score of 36. Echo revealed EF = 32%. After Heart Team discussion, CABG was declined due to liver cirrhosis and multiple comorbidities. Patient is now planned for high-risk PCI of calcified left main bifurcation using Impella support and Rotational Atherectomy +/- IVL.


Q You believe the main utility of CFR would be for discordant lesions?
A. Overall CFR value alone has less predictive value for longterm MACE compared to FFR/iFR prediction. It does add some value to predict events on FFR/iFR negative pts. Overall, it seems that CFR assessment is not expected to become in the mainstream of physiological testing in PCI procedures.
Q How often are you using coronary physiology at your institution?
A. Physiological testing is done in over 62% of coronary cases at Sinai. We are increasingly measuring IMR in nonobstructive CAD.
Q How often is it beyond just using FFR?
A. Overall physiological assessment at Sinai; FFR in 70%, iFR in 20% and RFR in 10% of cases. IMR is done in 15-20 pts per month (<2%); although increasing by making a set protocols for INOCA pts.
Q How much has coronary physiology impacted your outcomes?
A. Coronary physiology testing has made our cath PCI procedures appropriate as per the guidelines. Thus in turn physiological testing will improve overall outcome of CAD pts by avoiding unnecessary stenting in borderline cases.
Q We still do not comprehend leaving the critical RCA lesion alone?
A. RCA lesion is complex yet critical and staged PCI is planned after one month. We never had plan to leave it but always had plan to stage after taking care of the crucial LM lesion; which was the most prognostic lesion.
Q Would it be wrong to do that first before tackling the more challenging LMCA?
A. In this pt with issues of bleeding and low platelets, if only one lesion needed to be fixed for long term prognosis, was left main and then RCA. Hence intervening LM first was thought to be most appropriate.
Q Do you always do POT for LMCA?
A. Yes we always do POT for LM PCI. We do not routinely recommend POT for non-LM lesions as there are no scientific data (over FKBI) to support it.
Q What precautions do you need for POT? Have you seen trauma to the proximal segment or to the ostia in very proximal lesions?
A. Most important point to consider in POT planning will be at the time of stenting making sure that >6-8mm of stent will be in the MV to accommodate the shortest NC balloon. Then advancing NC balloon on the MV wire is safe. Sometimes, POT can cause over inflation, dissection or longitudinal stent deformity of the proximal MV segment. Largely POT is a safe technique.
Q Does the "rarely appropriate" definition cause more confusion?
A. The word 'rarely appropriate' replaced the word 'inappropriate' of old 2012 AUC criteria. This was done to avoid legal issues surrounding the Inappropriate PCI word and hence is welcomed in our documentation.
Q Can AUC be improved?
A. By enlarge, 2017 version of AUC is simple, scientific and practical. Few areas which still need extra work or improvement are LM and CTO PCI appropriateness.


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