PCI of Distal LM Trifurcation Lesion – May 2012

67 year old male with multiple CAD risk factors, presented on April 17, 2012 with new onset CCS Class III angina and + ETT (Duke Treadmill Score –10). Cardiac cath revealed 3V + LM CAD and normal LV function; Syntax score 31. CABG was recommended but patient declined CABG and underwent PCI of sub total mid RCA using Promus Element DES. Now planned PCI of distal LM trifurcation lesion.

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Q&A

Q Would you perform PCI if this patient was your father: a trifurcating LMCA and RCA and aortic valve disease?
A. This case has Class I indication for CT surgery (CABG x3 + AVR for AI); that is what we recommended to the pt. Pt has consultation with Heart-team including CT surgeon but refused CT surgery and hence PCI was offered. Yes, if my father decides the same after full explanation of benefit of CT surgery; I will personally do the PCI on him.
Q At what level of Aortic Valve disease would you not use an Impella catheter?
A. Moderate+ AI (+++) or >mild AS (AVA<1.2cm2) will be the situations where I will not use Impella.t
Q Similarly, have you employed IABP in dire cases for up to moderate AI?
A. Yes only in moderate AI case, just like this pt; but not in mod-severe or severe AI case.
Q If this patient crashes, what hemodynamic support will you use, considering his aortic valve disease?
A. TandemHeart will be ideal while waiting for CT surgery OR or placement of LVAD by them.
Q Would TandemHeart be a consideration in such cases?
A. Yes TandemHeart will be a viable option (if you have that) otherwise surgical LVAD or rapid transfer to CT OR.
Q Should such trifurcating cases have a mandated surveillance angiography?
A. It is my routine practice to do surveillance angiography in these trifurcation LMCA disease. These cases have high MACE Rates even with current DES and technical expertise.
Q What other situations do you use surveillance angiography?
A. Other cases for routine surveillance angiography after LM PCI are: pts with significant residual lesions (such as in large Diagonal or OM) Or young pt requiring 3 or more DES during LM PCI.
Q What is the ideal (short) carina length one should aim for in SKS?
A. Single digit length carina preferably 4-5mm long.
Q How much would there be a role of platelet aggregation studies for such high risk cases?
A. Platelet aggregation study by VerifyNow assay has a very limited value even in these high risk cases, as where possible we are using dependable agents such as Prasugrel or Ticagrelor even in non ACS but high-risk PCI setting.
Q What clinical trials are forthcoming for bifurcating and trifurcating LMCA?
A. Ongoing EXCEL trial is including both Bifurcation as well as Trifurcation LM lesions, as long as Syntax score is <33.

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