Complex coronary cases
IVUS Guided PCI of Distal LM Bifurcation Lesion – July 2015
Views 1077

79 year-old male with hepatitis, cirrhosis and prior PCI of RCA in remote past, presented on June 12, 2015 with new onset CCS Class III angina and dyspnea. A stress MPI revealed 2mm ST-seg depression, but normal myocardial perfusion. Patient underwent Cath revealing distal left main bifurcation with prox LAD and circumflex disease with normal LV function and SYNTAX Score of 26. Heart Team discussion declined CABG due to cirrhosis. Now planned for IVUS guided PCI of distal left main bifurcation lesion.

50:51

Q&A
Q
Do you feel that the results of CANARY and of your Imaging paper will contribute to getting FDA approval for OCT or NIRS?
A.

OCT presently is approved by most of the major insurance careers and is approved on the Ambulatory basis (just like FDA). For inpatients it is part of the PCI DRG. On the other hand NIRS is not reimbursable and these two trials do not make the strong case for its approval. CANARY trial showed that we could not prevent Procedural MI even in large LCBI lesions and Dr Kini's paper showed that it is the plaque cap thickness detected on OCT more then LCBI on NIRS which causes procedural MI.


Q
In light of your recent publications, is there still a niche indication for NIR spectroscopy?
A.

NIRS still remains an investigational tool and can not be used clinically in our decision making.


Q
If we have confirmatory data of TCFA by OCT, should the TCFA segment be stented prophylactically?
A.

Actually few small trials using both IVUS and NIRS are looking into this hypothesis; that will there be benefit of stenting (especially with Absorb BVS) of these high risk thin cap nonobstructive plaques with high LCBI. Hence we need to wait for the results of these studies (SECRET, PROSPECT II- ABSORB).


Q
Where does Cangrelor fit for reducing peri-procedural MI?
A.

Cangrelor will fit synergistically with Bivalirudin use especially in STEMI cases. It will be useful in Pts where preloading of P2Y12 receptor could not be achieved or is awaited to know the coronary anatomy. It will be very useful as the bridge therapy for Pts undergoing non-cardiac surgery within 6 months of high risk DES implantation.


Q
In the NY state database, what is the incidence of peri-procedural MI at Mount Sinai Heart?
A.

At Mount Sinai incidence of peri-procedural MI is 3.2% if CK-MB > 5X is considered and 1.4% if > 10X is considered. NY state now do not track peri-procedure MIs and only tracks trans mural MIs post procedure.


Q
Overall, is SKS your preferred strategy for bifurcating LMCA?
A.

For distal LM bifurcation stenting SKS is the preferred approach, if both branches have the obstructive lesion and are >2.75mm size.


Q
In what situations will you overlook the contributory effects of downstream lesions and use FFR for LMCA?
A.

FFR for assessment of LM lesion will be useful in ostial lesions and where IVUS is difficult or can not be advanced.


Q
Is your IVUS use decreasing for LMCA?
A.

We do about 10% IVUS guided PCI of LM and that number has been constant for last 10 years.


Q
What do you consider the best three indications in 2015 for OCT?
A.

best 3 indications of OCT in 2015 are: 1) to identify the exact cause of stent thrombosis 2) to identify the lesion morphology in nonobstructive lesions in STEMI Pts 3) to evaluate the optimal Absorb BVS deployment and at follow up evaluating its resorption.


Q
Would you do this LMCA case via wrist access?
A.

Yes we have done LMCA PCI trans- radially in cases of limited peripheral access. TRI still only makes <5% of our LM PCI compared to 20% of non-LM PCI.


comments

Leave a Reply

Your email address will not be published. Required fields are marked *


By submitting this form, you are consenting to receive marketing emails from: Mount Sinai Hospital, One Gustave L. Levy Place, Box, New York, NY, 10029, https://ccclivecases.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

suggestion
Suggestions
Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Views 370

Case and Plan: 65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to […]


Complex prox RCA CTO Recanalization via Retrograde Approach – February 2021
Views 142

56-year-old male presented with Class III unstable angina and positive stress MPI for significant inferior ischemia. A Cardiac Cath on November 20, 2020 at outside hospital revealed 2 V VAD: 85% mid LAD, 70% D1 and CTO proximal RCA with distal vessel fills retrogradely via septal collaterals (J-CTO Score 3), LVEF = 50% and Syntax […]


High-Risk Complex PCI of Diffuse Multivessel CAD – January 2021
Views 453

  Case and Plan: 45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score […]


Extremely Tortuous Angulated mid LAD Diagonal Bifurcation Lesion – December 2020
Views 620

Case and Plan: 75-year-old female presented with new onset CCS Class II angina and positive stress MPI on November 9, 2020 revealing moderate apical and inferior ischemia. A Cardiac Cath on November 24, 2020 revealed 2 V CAD: 95% proximal RCA, angulated tortuous 95% mid LAD bifurcation lesion, LVEF = 60% and SYNTAX Score = […]