IVUS Guided PCI of Distal LM Bifurcation Lesion – July 2015

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.

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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.

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