FFR Guided LAD PCI and Re-Attempt at LCx-OM2 CTO – July 2012

Case: 65-year old male with multiple CAD risk factors, had moderate lateral wall ischemia on stress MPI and presented on May 18, 2012 with new onset CCS Class II angina. Cath revealed extensive 3V CAD and normal LV function: Syntax Score 30. Patient declined CABG after heart-team discussion. Subsequently underwent successful PCI of multiple RCA lesions using Promus Element x3 and unsuccessful PCI of CTO LCx-OM2. Still has class I angina on maximal medical therapy. Now staged for FFR guided LAD PCI and re-attempt at LCx-OM2 CTO.



Q What do you feel is the true incidence of Inappropriate procedures in the country, based upon the deductions from your and Dr. King's pioneering work with AUC in NY State?
A. This can well be answered by publications in last few years from ACC/NCDR, NYS, North Carolina; Inappropriate PCI for stable CAD in USA currently is approx. 15%
Q Should doctors be fearful of the criteria or be proactive?
A. We need not be fearful but just be proactive making these criteria as the integral part of PCI and should be implemented when these pts are being scheduled for the cath/PCI.
Q What strategies have you found more useful at your hospital in dealing with AUC?
A. Uniform protocols and education of all involved in dealing with these pts, are vital ingredients of achieving minimum Inappropriate PCIs.
Q Does a heart team and AUC work hand in hand or they are mutually exclusive?
A. AUC tells us which pts are appropriate for revascularization. Heart Team approach guides us to the appropriate choice of revascularization; PCI or CABG. Hence both are essential and are in parallel.
Q Is your webcast going to regularly feature these criteria and help in dealing with them?
A. That is correct by bringing AUC criteria to the center stage as the part of discussion, will educate us and will certainly minimize Inappropriate PCIs. That is what we are emphasizing by our monthly Live web casts and annual Complex coronary symposium.
Q So you feel FAME 2 was wrongly terminated? Please elaborate?
A. My issue with FAME 2 was the criteria used to terminate the trial enrollment; repeat hospitalization which is a softer endpoint and unless there is decreased MI or death, it will not have a significant impact in our practice. In my opinion, we might have missed the golden opportunity of truly proving PCI as superior to medical therapy atleast in one stable CAD subgroup (who have FFR <0.81).
Q What is your overall use of FFR?
A. FFR use is increasing reaching to about 20% in our lab and likely to get the significant jump after final presentation of FAME 2 Trial in ESC, Munich at August end.
Q In the case you showed today, you down sized the burr size? How often do you do so?
A. Usually we select one burr and that is all what is needed (Burr:Artery ratio 0.4-0.5). Some cases we need to downsize the burr because burr selected is causing significant chest pain, ST segment changes or burr can’t cross the lesion after 7-8 runs of 18-20 secs (equivalent to about 2.5-3 minutes). This happens in about 5% of Rota cases.
Q What angiographic criteria should one look for possible downsizing of burr?
A. As mentioned above, it is more guided by clinical and EKG criteria but occurrence of angiographic slow flow will also force us to downsize the burr.
Q What maneuvers do you try with a Burr before downsizing it? Do you change technique or speed and so forth?
A. Only maneuver which can be useful in this scenario, is to increase the burr speed to 170-180,000 rpm from its usual 140-150,000 rpm. That has helped in many cases to cross the lesions as it certainly will improve the ablation efficiency but may cause more chest pain and slow flow.


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