Complex coronary cases
OCT Guided Complex Intervention of LM and Long Calcified Aneurysmal LAD – January 2020

Case and Plan:

76-year-old female presented with new onset CCS Class III angina with positive SPECT MPI for mild lateral ischemia. A Cardiac Cath on January 6, 2020 revealed 3 V + LM CAD: 70% distal LM, 80% proximal LAD/D1 bifurcation, 80% long calcified aneurysmal mid LAD, 80% LCx-OM1, SYNTAX Score of 35 and LVEF of 60%. In view of high SYNTAX Score, patient was referred for Heart Team discussion with recommendation for CABG, which was declined and patient opted for multi-vessel PCI. Patient underwent RCA PCI using Xience Sierra DES and discharged home. Now planned for OCT guided complex intervention of LM and long calcified aneurysmal proximal to mid LAD lesions.

So, what is the correct duration of DAPT?

The field of DAPT duration post DES is in flux at this time. Based on the recent RCTs, Aspirin should be given for 3 months along with Ticagrelor (or clopidogrel in elderly pts and in pts with high bleeding risk) for 1-3years and then switch to aspirin mono-therapy.

For ACS?

Above strategy (Prasugrel can replace Ticagrelor) for atleast 1year for ACS pts and can be reduced to 6M in stable or high bleeding risk pts.

And for stable lesion?

Above strategy for 6M in stable CAD pts.

When can one expect guideline changes for abbreviated duration of DAPT?

New DAPT guidelines are expected to be released in 3Q of 2020.

Is Aspirin completely on the way out?

Yes aspirin will be out after a short duration of 1-3 months.

Where will we have the application of QFR?

QFR is derived from a new software for coronary physiological assessment, which in my opinion will be useful in cases involving the diffuse disease where it will help to get the optimal PCI results.

What is your preference between Ticagrelor, Prasugrel and Clopidogrel?

Based on the ISAR React -5 trial results, we are now favoring Prasugrel over Ticagrelor in ACS pts less then 75yrs of age or Pt’s at low bleeding risk. In older pts and in pts with high bleeding risk, Clopidogrel remains the main agent. In stable complex CAD pts, Ticagrelor (based on TWILIGHT trial) is preferred over Prasugrel as we donot have data for Prasugrel in stable CAD pts.

I What has been the impact of ISCHEMIA in your institution?

Overall impact of ISCHEMIA trial is negligible at our institution as we have done a good job of educating our cardiology community appropriately.

Any impact from EXCEL?

So far EXCEL trial controversy also has not affected our referral patters for LMCA revascularization; high Syntax score cases getting CTS consultation before proceeding for PCI (which is being done in about half of the cases due to Pt’s and family preference).

Do you always perform co-registration during OCT?

Co-registration of angiographic view during OCT acquisition is recent tool being used routinely for last 2 years. It really helps us to localize the stent related issues, if any and then rectify them accordingly.


Join the Discussion

2 thoughts on “OCT Guided Complex Intervention of LM and Long Calcified Aneurysmal LAD – January 2020”

  1. Dr Ajay Aggarwal says:

    Can stent be placed in distal om if surgeon not willing to put graft there

  2. Amol Chavhan says:

    Question… while putting stent across aneurysms whether we need to dilate aneurusmal part to size of aneurysm

Leave a Reply

Your email address will not be published. Required fields are marked *

By submitting this form, you are consenting to receive marketing emails from: Mount Sinai Hospital, One Gustave L. Levy Place, Box, New York, NY, 10029, You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

Extremely Tortuous Angulated mid LAD Diagonal Bifurcation Lesion – December 2020
Views 337

Case and Plan: 75-year-old female presented with new onset CCS Class II angina and positive stress MPI on November 9, 2020 revealing moderate apical and inferior ischemia. A Cardiac Cath on November 24, 2020 revealed 2 V CAD: 95% proximal RCA, angulated tortuous 95% mid LAD bifurcation lesion, LVEF = 60% and SYNTAX Score = […]

Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Views 328

Case and Plan: 65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to […]

Complex Multivessel PCI in a High SYNTAX Score Patient – October 2020
Tags: | |
Views 394

Case and Plan: 74-year-old obese male on HD presented with CCS Class II angina and positive SPECT MPI on July 14, 2020 done as pre-op for renal transplant revealing moderate apical, inferior and inferolateral ischemia. A Cardiac Cath on August 20, 2020 revealed 3 V CAD: 70% mid RCA, 100% RCA-AV Cont, subtotal calcified mid-distal […]

Radial PCI of Long Complex Calcified LAD post TAVR – September 2020
Views 349

Case and Plan: 78 year-old-male presented on August 7, 2020 with progressive exertional dyspnea, NYHA class III. Workup revealed severe AS (AVA 0.7cm2), normal LV function and STS mortality of 1.1%. After heart team discussion, patient underwent successful TAVR using 26mm SAPIEN-3 Ultra with excellent results, AV area of 2.0cm2 and no PVL. A coronary […]