Complex coronary cases
OCT Guided PCI of Calcified LAD Bifurcation using 2-Stent + OA – December 17, 2019

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Case and Plan:

67-year-old male controlled NIDDM, presented with CCS Class I angina and positive stress echo for multi vessel ischemia. A Cardiac Cath on August 9, 2019 revealed 3 V CAD: calcified 80% mid LAD and D2 bifurcation, 70% distal LAD, CTO mid RCA and CTO proximal LCx, SYNTAX Score of 38 with moderate systolic LV dysfunction. After Heart discussion patient declined CABG and high risk multi staged PCI of all 3 vessels for complete revascularization was planned. Patient initially underwent successful PCI of LCx (3 Synergy DES) and then one month later PCI of RCA (3 Synergy DES). Patient is now planned for OCT guided PCI of LAD/D2 bifurcation using dedicated 2-stent technique after orbital atherectomy.

Why the lingering issues with EXCEL?

I have studied the EXCEL trial controversy very extensively which is mainly started by an European CT surgeon (Dr David Taggart) and now European Cardio-Thoracic surgery network is involved. There are 2 lingering issues; 1) not including the statement of higher Death in PCI arm in the conclusion section of NEJM paper; which I agree should have been done but even now should be added in the amended in the NEJM paper and 2) about the definition of MI different then what was originally planned (10x CKMB elevation). I do not agree with this issue, to present the data by Universal definition of MI (which reportedly higher in the PCI group vs CABG). There was no change the MI definition after the start of the trial nor it was modified in any of the publications.

Who is to blame for the controversy?

In nutshell, it is the unhappy European CT surgery community led by Dr David Taggart, who has escalated the EXCEL controversy to this heightened level. They are still not ready to accept the final 5-Yr results of EXCEL trial that PCI is equivalent to CABG for the primary endpoints of death/(predefined)MI/Stroke.

Are you planning to publish a response/editorial?

EXCEL leadership has sent a 6 page response to European CT society. We are waiting for their reply and to make the response for public knowledge.

Has BBC further flared the problem?

BBC being such a big network and community outreach, has certainly raised the controversy to the highest international level.

Should NEJM redefine some issues?

Actually, NEJM editors have already made the statement that no change is needed in the 5-Year EXCEL trial manuscript.

Are you planning a follow up of this issue?

I personally believe that we have discussed all the issues on this topic of EXCEL controversy and hence do not plan any further discussion on this topic on our ccclivewebcast. Yes, if some major revelation on this topic occurs in future, then only we will revisit the issue.

Do you believe EXCEL has altered the equilibrium and harmony between cardiologists and surgeons?

Yes a little bit but only out of USA. There has been no controversy in US CT surgical community so far.

Has ISCHEMIA affected your referrals?

ISCHEMIA trial results have not affected our cath referrals yet. But it is too early to judge and some impact may occur after its publication in print form. Main impact will occur only if it’s results are incorporated in the guidelines or by the insurance carriers; Enforcing the practice of initial optimal MT for 2-3 months before referral to the cath lab of a stable symptomatic CAD Pt.

Has the press response been similar to post-COURAGE?

Actually COURAGE trial had a major impact clinically as well as by the press and media. So far press and media impact is very little after initial 1-2 days of the AHA presentation.

What is the positive from ISCHEMIA?

Most important positive finding of the ISCHEMIA trial is that first time in the history of RCT, PCI has shown to reduce the incidence of spontaneous MI over MT alone in the stable CAD pts. That is really a plus point of PCI.


Join the Discussion

4 thoughts on “OCT Guided PCI of Calcified LAD Bifurcation using 2-Stent + OA – December 17, 2019”

  1. Ajay Agg says:

    Excellent session…Please discuss diet in next session

  2. pravir lathi says:

    Wonderful yoga presentation and nicely explained ischemia trial from interventional cardiologist prospective.

  3. Dr Subramanya Upadhyaya says:

    I am an Interventional Fellow from UK. Sorry, I had missed this session fantastic session. Watched it now…Very informative for the Operators’ as well as the patients’ health. I have personally seen Dr Sharma, Dr Kini and Dr Mehta in TCT conferences. However, I was pleasantly surprised by their young look in their professional costume (not in their cath lab leads/gowns) and now I understand the secret behind the same. It is very important that the Yoga preaching comes from the interventionist out of their experience and it has really impressed / motivated me to start practicing from today. Many Thanks for this wonderful session.
    May I suggest Dr Kini to come up with an app for “YOGA 4 Interventionists”.

  4. dr raja ramesh says:

    excellent session

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