Imaging Guided PCI of LM Bifurcation using RA and Mini-Crush Technique – May 2024

Case and Plan:

79-year-old morbidly obese male presented with unstable angina & negative troponin. A Cardiac Cath on March 29, 2024 @ OSH revealed calcified 3 V + LM CAD: 80% distal LM bifurcation with additional 70-80% lesions in LAD and LCx, subtotal proximal RCA and totally occluded mid RCA with SYNTAX score of 42 and LVEF 55%. CABG was recommended, but strongly declined by the patient. Patient is now planned for imaging guided PCI of LM bifurcation and additional lesions using rotational atherectomy and Mini-Crush technique.


Q What is the appropriate price for an Impella catheter in poor countries?
A. The appropriate price of Impella catheter in developing countries should be around $4000, compared to $25,000 currently. Then only, we can expect the widespread adoption of this important technique. ECMO cannulas cost $1500 and hence it is commonly used for high risk PCIs and for cardiogenic shocks in developing countries.
Q Is the high price of Impella creating the situation where its use for the most needed cases is not happening?
A. That is correct that Impella use in developing countries is seriously hampered by its price and is not being used despite appropriate indications. ECMO as the cheaper but less effective technology is being used more commonly.
Q How promising can the Potassium Nitrate situation become for CIN?
A. The data of Potassium nitrate in reducing CIN is very convincing but so far there has been no enthusiasm about its use. I have enquired from few of the busy Cath labs, and no one is using it so far. We have not used it too.
Q Have we maxed out with the use of wrist access?
A. No we will continue to increase our radial procedure by increasing our thresholds for Cath to 70% (currently 55%) and PCI to 50% (currently 35%). Overall data are convincing that increases radial procedures are associated with better outcomes especially lower bleeding and vascular complications and lower mortality in MI pts.
Q Is there a magic number for the use of imaging in coronary interventions?
A. It appears that most of the benefits of intracoronary imaging (ICI) occurs in complex lesions. Hence use of ICI in 40-50% of PCI will be optimal balancing the cost, time and effectiveness.
Q Do we even have further to go for reducing PCI for stable lesions?
A. Actually we are now discussing how to appropriately increase the PCIs for stable lesions in SIHD. Orbita-2 and Prevent trials are the prime examples of possibly expanding the field of PCI in appropriate cases of stable CAD.
Q Based upon SIDNEY 3, what is the best ACS platelet therapy?
A. Based on the Sydney-3 data, DAPT for 1M followed by Ticagrelor (not clopidogrel) mono therapy is optimal antiplatelet therapy post PCI; keeping effectiveness and minimizing bleeding.
Q In today's case, was the LCX ostium the true challenge?
A. Yes in today’s case, LCx ostium was the true challenge as well as it gave us the most educational experience in the case. In the end all lesions were well optimized on angio as well as on ICi.
Q Did IVL help or hurt in this case?
A. IVL use did help but only marginally in today’s case. These are all learning points.
Q Are you completely avoiding IVL in Left Main cases?
A. No we are not completely avoiding IVL in LM lesions but exert extra caution in its use and sometime do only 5 shocks at each time rather usual 10, thereby reducing the ischemic time.


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