Complex coronary cases
Complex High‐risk PCI of Unprotected LM Bifurcation – Jan 2013

68‐year‐old male with multiple CAD risk factors, CCS Class III an‐ gina and low risk MPI presented on 12/28/12. Cath revealed 3 vessel and left main disease and hyperkinetic LV function (SYNTAX score 33). Patient had heart‐team consultation and CABG was strongly recommended but declined by the patient. Now scheduled for complex high‐risk PCI of unprotected left main bifurcation.

1:11:08

Q&A
Q
How do you justify treating a seemingly "inappropriate" lesion?
A.

I agree fully that CABG is the preferred approach in this patient, and that is what precisely we did. Pt was seen by the CT surgeon but strongly refused CABG and went home. Now we had ethical dilemma of percutaneous revascularization or not in this high risk patient. We were confident that we will be able to revascularize safely the left system and leave CTO RCA alone. That is what was done to this difficult pt after careful and thoughtful deliberation. As I mentioned I will take the same approach even for my father or brother.


Q
Who constitutes a Heart team in your hospital?
A.

Heart team consists of CT surgeon, referring or treating cardiologist and the interventional cardiologist and presents the opinion of the team to the pt and the family. In this discussion, Interventional cardiologist should take the back seat and let other team members take the lead on discussion and recommendations; to avoid the bias. Interventionalist who does the cath, will be the part of the Heart team for initial recommendation and discussion. In the current case, Dr Kini was the Interventionalists and she was involved as the Heart team Interventionalist member.


Q
What is the role of platelet testing in this case?
A.

Despite the lack of convincing data for routine platelet inhibition (PI) testing, we do measure PI by VerifyNow (Accumetrics) assay in high risk pts on clopidogrel before discharge and if PRU is >230, then switch clopidogrel to either Prasugrel or Ticagrelor. We don’t perform PI testing if pt is on Prasugrel or Ticagrelor due to their consistent dependable PI.


Q
IVUS mandatory? Also if IVUS does not show concentric calcium, will you still use Rotablator?
A.

IVUS is preferred but not mandatory for ULM interventions and there is non-randomized data from LM-Compare study, where DES done with IVUS trended towards lower mortality at 2-yrs versus no IVUS. Even in the ongoing contemporary EXCEL trial of ULM, IVUS use is not mandatory. We do use IVUS in about 20% of our ULM PCIs, largely with 2 stent approach and to evaluate some angiographic haziness or dissections. Also, if there is no mod-severe calcification on angio or >3/4th arc of concentric calcium on IVUS, then Rotational atherectomy is not indicated for the ULM PCI.


Q
Please provide a concise rationale on how you choose between Angiosculpt and CBA?
A.

Both are effective devices in scoring the none or mildly calcified ostial lesions; If longer lesions and more calcified, then we use AngioSculpt otherwise Flextome CB is used in the majority.


Q
Any comparison available for newest stents and CABG for ULMCA interventions?
A.

ISR-Left main study evaluated Cypher vs. Taxus and were comparable in terms of all components of MACE. Another trial compared Cypher with Xience and did not find any difference between 2 DES. In my opinion, both Xience and Promus element DES will be equally effective in ULM PCI. EXCEL trial will be the final answer as to how the newer DES of Xience will fare against CABG in moderately complex ULM lesions (Syntax score <33).


Q
What is your favorite DES for ULMCA? What is you 2 stent technique for distal ULM bifurcation?
A.

Xience family is my favorite DES for ULMCA because of access to the side branch and very low incidence of stent thrombosis even in complex cases. In ostial ULM lesions, Promus element DES due to lack of elastic recoil is preferred. Simultaneous-kissing-stent (SKS) technique is the preferred approach of 2 stent deployment at our center.


Q
What DAPT and duration do you recommend for ULMCA?
A.

With the newer DES, we are continuing DAPT for one year only after ULM PCI. This was evaluated in the Xience USA registry where high risk PCIs such as ULM, had routine discontinuation of DAPT after 1 year, yet with extremely low ST rates (<0.2%). As far as the type of DAPT ADP receptor blocker is concerned, if there is no high risk for bleeding, then Prasugrel is preferred for it’s consistent and reliable platelet inhibition action.


Q
How skilled should an interventionalist be before performing such skilled procedure?
A.

ULM PCI using single stent technique or involving ostial or body lesion, can safely be done by a trained interventionalists. ULM cases of complex distal bifurcation, heavily calcified lesions and one with occluded RCA, should only be done by the very skilled interventionalist. That is what we get referrals from the Tristate area for complex ULM PCIs; usually heavily calcified.


Q
Would PCI of RCA make the LM intervention safer?
A.

Yes if CTO RCA can safely be done, then it should be done before embarking on the ULM PCI. If RCA CTO has unfavorable features, then ULM PCI can safely be done, as it was done in this patient.


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