64 year old male presented with new onset CCS Class II angina and a positive stress MPI for anterior, apical and septal ischemia. A Cardiac Cath on November 7, 2017 revealed II Vessel CAD: proximal LAD CTO bifurcation (Medina 1,1,1), with 80% D1 bifurcation, 70% LCx-OM2 with a SYNTAX score of 30.5 and LVEF = 60%. Patient underwent FFR of the LCx, which was 0.91 (-). Patient is now planned for staged PCI of LAD CTO-D1 bifurcation with planned 2-stent technique.
QShould there be a follow up trial to ORBITA - in Europe?
A.I agree that we should have 6month followup of the ORBITA trial because pts with +FFR had higher events of urgent revascularization at 5-7 months followup which led to premature termination of FAME II trial.
QWhat do you think will be the long term fate of the patients in the two arms of ORBITA?
A.I predict that many pts in the Sham PCI group on their own request or recommendation by their treating cardiologist will undergo PCI after 2 months when they were told that they did not have actual PCI.
QYou feel ORBITA will be old news by next TCT, or sooner?
A.I think it is already an old news as it did not have the fallout of PCI as we had after COURAGE trial. I still think that some insurance companies may mandate approval of Cath only first and then MMT and will approve PCI only if MMT fails as the second step/stage.
QIs there a good message for interventional cardiologists from ORBITA?
A.Yes a simple message is that, PCI in single vessel CAD should only be done for symptoms of persistent angina, exercise limitation or ischemia on stress testing on MMT.
QWill payers get concerned with ORBITA or it makes no major difference as there is no change to guidelines?
A.I strongly believe that some of the insurance companies start approving coronary angio only and then maximize the Medical therapy (MT). If MT fails then only PCI will be approved. Or simply insurance companies should start mandating FFR measurements before elective PCI for stable pts; that PCI only if lesion has FFR of <0.81. This will be the right thing to do supported by various RCTs.
QIn 2017, what bifurcation technique is best for LMCA?
A.Dedicated 2 stent technique is better then provision stenting for LM bifurcation lesions. Preferred Type of 2 stent technique will vary based on the personal experience. Data have shown DK Crush as the preferred approach but requires multiple steps and others like Minicrush or Culotte are relatively simple and are also expected to give similar results. We routinely do Minicrush for distal LM bifurcation with excellent short and long term results (case # 100 was Minicrush for dLM bifurcation).
QWhat are wire passage times for CTO at Mt. Sinai?
A.Average wire passage time for antegrade CTO wire recanalization at Mount Sinai is 22 minutes along with the mean total procedure time of 55 minutes. Average wire passage time for retrograde recanalization is 45 minutes.
QBreakdown for antegrade and retrograde approach of CTO?
A.We have 95% Antegrade (usually 2 attempts) and 5% Retrograde technique for CTO recanalization at MSH.
QDo you think this may happen - during a complex PCI, the operator wants to review the Bifurcaid App?
A.Bifurcaid App really is a great resource for a practicing interventionalist. It’s main utility will be to plan the case before the actual procedure. In rare situation, if case is not proceeding as planned, it will reasonable to go thru the trouble shoot steps from the App.
QBest trial at TCT? Culprit shock?
A.Three best trials from TCT which will change our Interventional thought process and strategies are Culprit Shock, ORBITA and DK-Crush V.