IVUS Guided PCI of Unprotected LM Bifurcation – March 2012

Case: 61-year old female with prior PCI of RCA and LAD presented with crescendo angina CCS Class III. No stress test done. Cardiac cath on March 2, 2012 revealed 2 vessel and left main bifurcation disease with normal LV function, Syntax Score 23. CABG was declined due to liver cirrhosis. Patient is now planned for IVUS guided PCI of unprotected left main bifurcation.

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Q&A

Q Do you use Reopro in addition to Angiomax in this case? What is the anticoagulant of your Choice and goal ACT?
A. In selected high risk PCI cases (approx. 15%), one like this, we will use GP IIb/IIIa inhibitor bolus (2 boluses for Integrilin and one bolus for ReoPro). This approach is consistent with the various trials of Angiomax where GP inhibitors were used as bailout in 4-8% of cases (Replace 2, Acuity and Horizons AMI). Integrilin is used in most cases and ReoPro is reserved for STEMI cases. Angiomax is used in all. We use GP IIb/IIIa inhibitors as the planned agent rather than the bailout use. Cases we will use GP IIb/IIIa inhibitor will be pts with LVEF <30%, bifurcation ULM requiring Rotablator, multiple side branch PCIs and ADP receptor blockers loading on the table in these cases. ACT is always confirmed to be >300sec before the start of PCI even with Angiomax. In the past when using heparin and GP IIb/IIIa inhibitors, ACT was kept between 225-250 sec as per ESPIRIT trial.
Q Do you recommend us to use IABP during PCI?
A. Yes IABP should be used in ULM cases which requires tremendous manipulation of devices (like Rota and 2 stent approach) and LVEF is 30-50%. In pts with LVEF <30%, we will recommend use of Impella device for these cases to get optimal PCI results.
Q Could you have considered T Stenting approaching the Cx 1st? Using this technique, is there a recommended angulation between the LM and LCX for this to be effective or any chance of failure?Can we use run through wire in both LAD and Circ in this case ? Can we draw the RunThrough wire jailed by stent?
A. As I showed in my square grid of preferred stent approach in ULM bifurcation, 2 stents with SKS technique is commonly used in large size bifurcations involving both branches and angulations. Yes other techniques such as T Stenting and Crush stenting can also be used. Also we do jail all kinds of wires (RunThrough or Fileder) and then can be safely removed as long as wire is not bent or stuck in a small distal branch.
Q Which unprotected LMCA will even you not do?
A. ULM cases with high Syntax scores should preferably referred for CABG and we should not offer PCI as the first line approach. If pts refuses CABG then PCI can be done in any ULM case. Only situation, I will not perform ULM PCI, will be where there is no femoral access for LV assist device use (IABP or Impella) and LVEF is <30%.
Q Are you routinely following the EuroSCORE, in addition to the SYNTAX? Do you then employ the Global Risk Classification? Or, do you feel it is an overkill to do so in most cases?
A. Presently we do not calculate EuroScore or STS score for Global risk calculation. Soon (as of May 2012) we will start calculating both these scores as per the ACC guidelines as Class I recommendation to calculate these scores in pts with complex CAD and so that we can have the optimal Heart Team discussion. Hence I believe, we need to go beyond calculating Syntax score in pts with complex CAD as we are presently doing for TAVI/TAVR cases.
Q So far as the distal LM bifurcation is concerned, what feature do you pay most attention to – plaque distribution, bifurcation angle, or both?
A. Most important feature to consider for LM bifurcation will be angulation of LCx and LAD and second being the individual ostia involved (& narrowed). If angle is small, then second bailout stent placement may be difficult and poses additional technical challenges.
Q Regarding unprotected LMCA interventions, do you use in 100% of the cases - IVUS, Heart team approach and SYNTAX?
A. In ULM intervention, we use: IVUS in 25%, Heart team approach in 100% and SYNTAX in 100% of cases.
Q Which modality holds more promise for LMCA – IVUS or OCT?
A. We have data for IVUS only and very little data for OCT in ULM PCI. Hence IVUS or FFR should routinely be used for PCI results optimization.
Q How do you choose between crush/mini-crush, SKS and stent across strategy for LMCA bifurcations? What is your proportion of such strategies at your institution?
A. As I showed in the square grid, large stenosed bifurcations should get 2 stents and single cross over stent be preferred if both bifurcations are not involved and one branch is small (<2.5mm). With that strategy in mind, at our center, use of various stent approach for ULM bifurcation as follows; Single stent in 50%, SKS in 40% and minicrush or TAP in 10%.
Q Congratulations for your stellar performance in NY State PCI report card! What factor do you think contributed most to your lowest AUC rates and to your large PCI volumes?
A. Factors for lowest inappropriate AUC rate are; uniform protocols of case selection and educating referring MDs to schedule stable CAD pts only after failed maximal medical therapy, unless there is high risk non-invasive scan. Factors for highest PCI volume are; Lowest PCI complications, taking all the tough & complex cases and outreach network of physician going into the local community to provide cardiology services.

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