Complex coronary cases
Revascularization of Calcific LM Bifurcation (edited case) – January 2019

86 year old female with chronic stable angina CCS Class II and positive MPI for two years being managed on medication. A Cardiac Cath on May 14, 2018 revealed severed calcific 2V + dLM bifurcation disease, prox LAD focal aneurysm and normal LV function and SYNTAX Score of 30. CABG was recommended, but declined by the patient and family due to old age and poor coordination. Patient is planned for revascularization of complex calcific left main bifurcation using rotational atherectomy and planned one-stent crossover technique with IVUS guidance.

Moderator: Sameer Mehta, MD

19:59

Q&A
Q
The cardiology societies should respond to articles such as the one you presented today calling PCI "fraud."
A.

I fully agree that cardiology societies need to be involved in this kind of statement. I will even say that Journals should also curb and reject this kind of language in editorials.


Q
How much is the incidence of inappropriate cases globally - more than in the U.S. or less?
A.

In the USA now, approximately 10-12% are inappropriate PCIs as per latest NCDR data. Out of the US, this number is likely to be very small because much higher proportion of PCIs are for ACS (where inappropriate is rare) and majority of stable CAD pts gets trial of MMT before undergoing cath/PCI.


Q
Does Mt. Sinai have policies in place that rigorously review AUC criteria?
A.

Absolutely, we have a very strict policy of assigning the PCI pt after cath into the proper AUC category and have extra discussion with the team members (referring MD and cardiologist) before proceeding for inappropriate PCI, if at all. There are some scenarios where PCI is clinically indicated but is inappropriate by the AUC criteria such as significant lesion causing VT, severe lesion preop for noncardiac surgery but negative or unavailable stress test and severe lesion in a patients planned for TAVR who usually are not on antischemic meds and do not have stress tests.


Q
How has the meticulous insertion of AUC helped ccclivecases.org?
A.

Using AUC in every CCC Live Case from Jan 2010, has really uplifted the global understanding of the AUC in daily interventional practice. We all are proud of it and I have been invited in ACC and AHA 2012-15 and many other medical centers to give lectures and grand rounds on the topic of implementation of AUC for PCI.


Q
Has AUC begun emerging in structural heart and for peripheral interventions?
A.

Yes, there are AUC for TAVR and MitraClip Structural procedures but that is more for appropriate indications of the procedure. In my opinion, AUC has little importance in structural cases as all Pts are discussed by the Heart team which include Interventionslist and CT surgeons and appropriate treatment decisions are made considering the Pt in its entirety and not just by some numbers. Frailty is one of them. I am not aware of AUC for Endovascular procedures. There are AUC criteria for cardiac cath, echo and nuclear stress tests.


Q
How will you follow the aneurysm in today's case - or, it needs to be simply left alone?
A.

Yes, residual aneurysm in today’s pt does not require any further surveillance. In due course of time it will even become smaller due to no flow in the aneurysmal sack behind the stent struts.


Q
Have you established a criteria for using covered stents for such aneurysms?
A.

As you know Coveted stent (JoMed Graft master) is not approved for this purpose of closure of the aneurysm. If need to be used fir this purpose, it will require IRB permission. Other peripheral covered stents which do not require IRB approval, can be used for this purpose (vessel size has to be 5mm+). Hence, we have no set criteria for coronary aneurysm closures. We have published a case of closure of a 11mm aneurysm in RCA, just by use of Xience stent (Engstrom A and Sharma S. JACC CV Intervent 2017, 10;e65).


Q
While performing crossover stenting, do you have a favorite stent?
A.

All currently FDA approved stents are good for LM crossover stenting and side branch hole can be opened by KBI upto 3-3.5mm. We have maximum data with Xience DES in this field via EXCEL trial.


Q
What do you consider the best event in Interventional Cardiology in 2018?
A.

In my opinion, Global Leaders Trial of abbreviating aspirin use to one month, although was negative but has opened the door of shortening the aspirin use post DES. There was no difference in the incidence of ST or bleeding in the trial. Hence future trial will focus on removing aspirin all together to reduce bleeding post PCI yet keeping ischemic protection by use of a potent single antiplatelet agent such as Ticagrelor.


Q
What do you consider is the most important issue we should tackle in Interventional Cardiology in 2019?
A.

We still have challenges for CTO recanalization and hence it will remain the top interventional issue to be tackled in 2019.


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