71 year old male with multiple CAD risk factors presented with NSTEMI, pneumonia and septic shock in October 2018. Patient developed acute respiratory failure requiring intubation and gradually improved and extubated. A Cardiac Cath on November 9, 2018 revealed 3 V CAD: 50% distal left main, 80% severely calcified multiple mid LAD lesions, 70% prox LCx and 90% LPL lesions, 70% mid RCA lesion with LVEF 45% and SYNTAX Score of 28. The Heart Team recommended CABG, but was declined by the patient and family. The patient is now planned for OCT guided multi vessel PCI using Orbital atherectomy and multiple DES.
Moderator: Sameer Mehta, MD
Q&A
Q
What is your present management strategy for AF-PCI?
A.
Our best strategy has been Xarelto 15mg daily and plavix 75mg daily with aspirin 162mg only on the day of PCI: supported by Pioneer AF trial. If newer P2Y12 inhibitor is indicated then use Brilianta 60mg twice daily or Effient 5mg daily. This is adopted by majority of our interventionalists but some still also use aspirin 81mg daily for 1-3 months.
Q
Based upon the new data you presented, but not in the guidelines, what will be your strategy now?
A.
Augustus trial data support to eliminate aspirin after the PCI day with use of Eliquis. Hence this will endorse our existing policy and will certainly convince the remaining interventionalists to adopt this policy of eliminating aspirin all together in these cases.
Q
What do you speculate would be your strategy next year?
A.
We will also be using Eliquis instead of Xarelto with plavix in this scenario and no aspirin at all.
Q
In 2019, with newest DES, what is your dose and duration of Aspirin?
A.
We will wait for the results of TWILIGHT trial before abbreviating aspirin in DAPT therapy for 1-3 months. The trial will be presented in TCT this year.
Q
Radial/femoral keeps going up and down - you think the CTO Radial is the final word?
A.
Radial Intervention in my view has plateaued now to 50%; as we are definitely noticing some hand dysfunction and recent SAFARI STEMI radial trial comparing radial vs femoral access PCI in STEMI cases was totally negative for primary outcomes. Clearly one access being radial (usually left) in CTO cases is increasing and makes sense.
Q
In what percentage of your CTO are you using the strategy you described today - L Radial and R femoral?
A.
We are now using L-radial and R-femoral in about 40-50% of cases and both femorals in others with bilateral radials in <5% of cases.
Q
If you had today's case next week, will you opt for the Rotablator?
A.
It seems that Rotablator would have given us the better procedural strategy results in this case but final angiographic results were optimal.
Q
What could have been done different in today's case with the device, its selection or the technique?
A.
Perhaps using Rotablator and using a longer DES covering proximal LM segment would have been the better strategy.
Q
What caused the proximal dissection?
A.
Incomplete lesion coverage was most likely responsible for the proximal dissection of the LM.
Q
How did the case end - was that the final result or did you address the dissection and LMCA?
A.
As we ended the live case showing small dissection on OCT as well as type B dissection on Angio. Finally we ended up stenting the proximal LM dissection with another stent with successful results. Pt was discharged home the next day. We will show the final steps of completion in our April 16th webcast.
