Q&A
Q.
Did IVUS unambiguously help in this case?
A.
In today’s case, IVUS really did not make a clear cut difference on top of what we knew by angiogram.
Q.
Is routine imaging an overkill?
A.
I agree that routine IV imaging (IVI) is an overkill. I think that 40-50% PCIs (complex, LM bifurcation, calcified, CTO lesions) done with IVI will make a difference in clinical outcomes and is supported by recent both ESC and ACC guidelines.
Q.
In what lesions are you routinely using OCT?
A.
IVI is done in about 30% of our PCIs (about 110 per month); 90% IVUS and 10% OCT. IVUS is the default and frontline imaging tool and all Cath lab staff, fellows and faculty know to do it well and interpret easily. OCT is currently used mostly in the clinical research trials protocol and used rarely to understand the mechanism in multilayer ISR.
Q.
And IVUS?
A.
As said above most IVI in our Cath lab is IVUS. Soon we will be evaluating an imaging catheter made by Terumo which has both IVUS and OCT capabilities.
Q.
What are your views about the Class 1 recommendation of imaging for STEMI?
A.
I will not support it routinely to have IVI as Class 1 in STEMI. It’s ok to have it as Class 2a or 2b. Hence in selected STEMI PCI cases, IVI may help to detect residual lesion thrombus or dissection which can modify further treatment. Issue of detection of stent under expansion and then using high pressure balloon dilation could be problematic by causing slow flow by soft plaque/thrombus squeezing and distal embolization.
Q.
In this case, would IVL of either the LAD or the Diagonal have impacted the results?
A.
In today’s case, IVL alone would have been difficult to cross and yes after Rota, it may complement further plaque modification.
Q.
How much does imaging add to the time of the procedure and to the radiation exposure to the patient?
A.
Most IVI studies have shown that imaging adds 5-10 minutes of the procedure time and 2-4 minutes of fluoro time. But benefits in complex cases outweighs these limitations.
Q.
Are you convinced about the data you presented from NYU about the CPK injury post PCI?
A.
Recent data from NYU about direct correlation of any level of CK-MB with 5-7 yrs mortality, is very intriguing and likely true. We as well as many others, did not find this relationship in lower levels of CK-MB elevation (<5X) at 1-2 yrs of f/u. This single center report with its inherent limitation, certainly will make us to take even slight elevations seriously.
Q.
Would you be changing your practice based upon this research?
A.
I will not be changing our practice based on this single observation. We have published 10 papers in this field and now are planning to do our 5-7 year follow up. Based on the results, will decide if any practice to be changed.
Q.
What are your individual indications for DCB at Mt. Sinai Hospital in 2025?
A.
We use about 15 DCBs per month; 10 are in the DCB trials of ISR or small vessels and 4-5 Agent DCB for failed IVBT ISR clinically. We rarely use DCB for denovo lesion side branch PCI. Clearly with improved payment with new CPT codes for DCB starting Oct 2025, its use will increase. I predict we will be using 30-40 DCBs per month (10-12% of PCIs) by 2026 end for various clinical indications.
