FFR Guided PCI of LAD and LMCA – Jan 2012

Case: 77-year old male presented with non-STEMI on August 30, 2011. Cardiac cath revealed 3V CAD (95% ostial RCA, 50% distal LM, 70-75% multiple lesions in LAD & 70% OM2) and near normal systolic LV function. Patient underwent PCI of culprit RCA vessel using Xience V DES. Patient has crescendo angina and is planned for FFR guided PCI of LAD + LMCA.



Q You emphasized a Heart Team Approach - are you universally using this at your institution?
A. Heart Team Approach started by SYNTAX trial and TAVI trials, has now been incorporated in recent 2011 ACC/AHA guidelines, making it a Class I recommendation for ULM or Complex CAD defined as Syntax score >22 and STS mortality of >5. At Sinai we routinely calculate Syntax score in our stable CAD pts and pts with score >22 are getting Heart Team consultation (comprising of a CT surgeon, Interventionalist and a clinical cardiologist). Some pts who are high risk for CT surgery such as with COPD with FEV of <1L, prior CVA in last 3 years, BMI >50 or short projected life span of <1 year are being excluded from this consultative approach.
Q For complex coronary interventions, LMCA, TAVI and for CTO - Heart Team for all these?
A. Yes Heart Team Approach is being used for TAVI, Unprotected LM CAD or Complex CAD with Syntax score of >22, many of them have CTO’s.
Q How much importance do you give to patient preference? A patient has a SYNTAX score of 36 but wants PCI? Do you and the surgeons, as a part of this Heart Team approach, discuss together with the patient?
A. Obviously patient’s preference is the final verdict but the concept of Heart team approach provides the unbiased data to the patient (stating pros and cons) outside the cath lab room and then let patient (& family) make the final decision. We have seen about 30% of pts despite the data in favor of CABG, decides for PCI and then are brought back for PCI (same day or next day).
Q Would you consider the Heart Team Approach and Appropriateness Use Criteria as the two largest ethical solutions that you have incorporated at your institution?
A. Absolutely yes and by instituting these practice guidelines in one of the busy cath lab in this ‘era of stent scrutiny’, keeping us scientific, and ahead of the curve.
Q Besides the ccclivecases, how are you teaching the value and importance of these critical issues to other institutions?
A. We volunteered for the NY State as the showcase site to demonstrate routine use of these quality measures in daily cath lab practice. Six NY sites and 3 sites out of NY have visited us and have incorporated our approach. Besides this, many other centers in the US have enquired about our these protocols along with the Ambulatory PCI protocols; of course we have sent the data to all.
Q Have these issues become integral part of your training program? Should they become essentials in the training of fellows, globally, since these are important issues faced by physicians beyond the United States?
A. I can’t agree more on this as teaching PCI does not only include doing the PCI correctly, but also should include when not to do and also when to get CT surgery consultation for overall benefit of the patient.
Q What made you incorporate the Chinese simulcast?
A. During numerous visits by Dr Sameer Mehta to china, there was tremendous demand by the Chinese viewers and hence made the Chinese simulcast. We expect to add Japanese and Spanish simulcast to our Live web series by the year end.
Q In cases such as the LAD done today, if you are convinced about the clinical history and the FFR is borderline, will you intervene?
A. Indication to do the PCI will be FFR of <0.8. With multiple lesions like the LAD tackled today, we now have learnt that some angiographic significant lesions with FFR >0.8 can be left alone (no stent) and yet do well on long-term (2 year FAME Trial data).
Q Which is your favorite long stent? Why?
A. At present Xience Prime 33 or 38mm is the preferred long DES because of ease of delivery and favorable long-term data especially very low Stent Thrombosis (ST) rates in the trials.
Q What do you see the potential for non-invasive FFR? Do you see the need for larger models of the DISCOVER FLOW kind of trials?
A. Best data still remains for the invasive FFR: First DEFER trial showed that it is OK to leave the lesions with FFR >0.75, then FAME trial showed that doing PCI of only lesions which have FFR <0.8 has best long-term outcomes and is cost effective, and Now FAME II trial showed that not doing PCI of lesions with FFR of <0.8, is detrimental despite optimal medical therapy and hence should have PCIs to reduce the F/U MACE especially urgent hospitalization requiring Intervention. Hence until we have such solid outcome data with non-invasive FFR, Invasive FFR will remain the gold standard of Interventional cardiology as far as decision making for PCI is concerned; ‘do it or not-to do it’.


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