Case & Plan:
47-year-old female with ESRD on HD, presented with CCS Class I angina and a markedly positive SPECT MPI for anterior and lateral wall ischemia. A Cardiac Cath on February 23, 2021 revealed severely calcified 1 V CAD: 90% proximal LAD and diagonal bifurcation (Medina 1,1,1), 80% mid LAD and SYNTAX Score of 23 with normal LV function. Patient is now planned for IVUS guided PCI of severely calcified LAD-D1 bifurcation using rotational atherectomy (step burr 2.0 and 2.25m) and dedicated two-stent mini-crush technique.
Q&A
Q
The calcified nodule was critically identified by IVUS. Could it have been characterized as well by OCT?
A.
Yes calcific nodule can also be identified by OCT as a translucent area with clear demarcation
Q
The decision to downsize the burr was more from the angulation and tortuosity in the mid LAD?
A.
Yes decision to downsize the rota burr in mid LAD was done due to sharp angulation for fear of perforation and the burr was having difficulty in moving forward. That clearly was the right decision.
Q
What are affective ways to reduce wire bias during rotablation (RA)?
A.
Actually there is no good technique to reduce wire bias as it occurs in the angulated and eccentric lesions. Use of Rotafloppy wire and active to & fro wire movement (after depressing the break release) during rotablation (RA) procedure may help to mitigate some of the wire bias. Actually wire bias can work in favor of ablation with rare instances of causing dissection/perforation.
Q
How would this nodule respond to orbital atherectomy (OA)?
A.
Calcific nodule does not respond well to OA, which works the best in concentric calcific lesions.
Q
To Cutting Balloon and IVL?
A.
Both Cutting balloon and IVL are not ideal for Calcific nodule intervention and RA seems to be the best suited for this lesion type.
Q
Where do you perceive the role of IVL?
A.
IVL will be useful in large severely calcified vessels (>3.5mm or so) to effectively modify the calcified plaque.
In these large vessels, RA with large burr can increase procedural complications and OA may not lead to the meaningful improvement in MLD.
Both RA and OA can work synergistically with IVL for some of these lesions.
Q
What are the costs associated with IVL?
A.
In my opinion IVL cost of $4000 each catheter at this time is prohibitive to be used commonly during intervention.
One catheter provides 80 pulses and is more are needed new catheter needs to be used.
Also there is no separate reimbursement for IVL which definitely will adversely affect the hospital finances.
Q
Would you expect another company to enter the IVL arena beyond Shockwave Medical?
A.
I am aware of one new project in development utilizing shockwave type technology but will take many years to come to the clinical market.
Q
Do you subconsciously aim for FFR >0.90 for your cases?
A.
Actually we don't aim or think about the post-PCI FFR value and just try to optimize the angio results and if needed use iVUS/OCT to validate the final results.
Q
Is the differentiation between Type 1 and Type 2 MI more relevant today because of reimbursement issues?
A.
There is no difference in reimbursement between Type 1 and Type 2 MI but important is to make the diagnosis and code appropriately. Over the years we have not been coding these Troponin elevations as MI and this field has now mushroomed with appropriate coding involving the dedicated personals for this task.
