Complex coronary cases
High Risk PCI of Unprotected LM Bifurcation (IVUS and LV Support) – January 2018

84 year old female with IDDM and prior CVA, presented with CCS Class IV angina after a small NSTEMI and had positive stress MPI with mild apical and anterior ischemia. A Cardiac Cath on January 2, 2018 revealed LM and 3V CAD: CTO of calcified proximal RCA, 70% distal left main bifurcation with 90% proximal LAD and 70% proximal LCx (Medina 1,1,1) and 80% mid LAD (Medina 1, 0,0) bifurcation with SYNTAX score of 41 and LVEF 50% due to inferopical hypokinesis. Patient underwent Heart Team discussion and CABG was declined due to advanced age and high STS score of 8.2. Patient is now planned for high risk PCI of unprotected LM bifurcation with dedicated two stent technique, IVUS guidance and possible LV support device.

Moderator: Sameer Mehta, MD


If an institution does not possess OCT, should they procure it?

Of the two invasive imaging techniques, IVUS is a must in the Cath Lab and then OCT.

If an institution does not perform iFR, should they invest the time and effort to train themselves?

Yes, iFR data are solid and can be preferred in cases where adenosine can not be given for FFR (such asthma, AS). Hence all Cath Lab should have iFR capability. The Volcano’s machine can do both FFR and iFR with the same wire.

Same for NIR, as Q1, should they procure it?

NIR is purely an investigational tool measuring Lipid core in the plaque and does not have long-term outcome data, hence not a must to have it in the Cath Lab; have ok only for research trials.

For which cases do you feel is IVUS absolutely essential?

IVUS is essential and reliable for for measuring pre-procedure MLA and detection of calcium. It is also useful in CTOs to identify the ostium of the occluded vessel.

Is there a particular IVUS that you prefer?

At present we have the most experience with BSC IVUS (iLab). Second is Volcano IVUS which has been integrated with Phillips Inc.

What is the situation with reimbursement for OCT?

There has been proper reimbursement for OCT; always for the physician and for only ambulatory cases for the hospital. OCT reimbursement for inpatient is part of the DRG of the procedure.

Beyond what you discussed today, is there additional promising technology in imaging that excites you?

There is nothing on the recent horizon but certainly will like to have a single catheter which can do IVUS/OCT and FFR/iFR. I am sure we will have this kind of catheter in our lifetime.

pd/pa is how we used to do PTCA 25 years ago. Why is this a new and exciting concept?

Just because it is simple and is being done with the wire and not with the over the wire catheter (then we used to remove the wire and connect catheter to the transducer; which used to be done in early PTCA days). Also now Pd/Pa data are simple and comparable to iFR data which is proprietary.

Why do you feel is reimbursement so low for imaging modalities?

This is just like vascular closure devices which are being considered as the part of the procedure and is incorporated in the DRG and hence no separate reimbursement for the imaging procedures coupled with PCI.

In 2018, do you feel we will use more imaging or less?

Overall use of imaging during intervention can only go up if randomized trials will show their positive impact on clinical outcomes. Otherwise their use will remain in mid teens; currently 16% as per latest ACC-NCDR data in USA.


Join the Discussion

5 thoughts on “High Risk PCI of Unprotected LM Bifurcation (IVUS and LV Support) – January 2018”

  1. DR JOY SANYAL says:

    i am from india and would like to know that for crossing the diagonal you could have used Sion Blue which i think is very suitable and that the decision to do POT should have been taken as a first step only instead of trying to cross first ,then do POT and then again recross.
    the case was very informative and i am a regular viewer of your webcasts though i watch it deferred live because of time differences.we do lot of ROTA here but the ease with which your logistics are arranged is striking because here ROTA is like organising a festival, all the logistics herein, still then i do at least 4-5 cases a month.

  2. Ralph Kunkel says:

    Great case

  3. BABA AMEUR says:

    Top of the top case and presentation.
    Amazing skills

  4. dr.ahmad rababa says:

    very intresting and challenging case… well done

  5. Iftikhar Ahned says:

    Can we save video for off line watching?

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