IVUS Guided PCI of Unprotected LMCA and LAD – Oct 2015

77 year-old female with moderate COPD and known non-obstructive CAD now presented with crescendo CCS Class III angina and a positive stress MPI for mild infero-apical ischemia. Patient is on maximal tolerable doses of anti-ischemic therapy. A Cardiac Cath on October 19, 2015 revealed significant ostial left main (LM) and ostial LAD disease with normal systolic LV function and SYNTAX score of 24. After Heart Team discussion PCI is recommended. Patient is now planned for IVUS guided PCI of unprotected LMCA and LAD.

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Q&A

Q If results from re run of IVUS was non-confirmatory, would you have proceeded to do an FFR?
A. Yes as FFR has shown to be predictive in these complex cases with angiographic intermediate stenosis.
Q Any role of OCT in this case?
A. OCT is a great tool for plaque morphology visualization but MLA on OCT requiring intervention has still not been validated. We know by IVUS, MLA of 4mm2 of non-LM and 6mm2 of LM are predictive of future events.
Q From your excellent editorial, for which patients would you continue DAPT after 1 year?
A. Following group of PCI pt with low predicted bleeding risk will be best suited for prolonged DAPT beyond 1 year: post MI, post CABG, recurrent restenosis, any stent thrombosis, post IVBT etc. Clearly prolonged DAPT is contraindicated in pts with moderate to high bleeding risk at baseline.
Q For which patients, long-term Ticagrelor?
A. PCI pts described above and now based on Pegasus trial data, any post MI pt.
Q 60 mg Ticagrelor?
A. Yes Ticagrelor 60mg twice daily will be ideal for prolonged DAPT as will result in less bleeding and similar efficacy as 90mg.
Q Can Prasugrel be used for these patients long-term?
A. Yes Prasugrel as the prolonged DAPT post stenting is recommended (DAPT study) but not as the secondary prevention post MI as has not been proven.
Q What happens to Aspirin long-term, 81 mg or none?
A. Still aspirin 81mg lifelong is recommended as the part of DAPT until we prove that dropping aspirin after 3 mths with Ticagrelor is safe (Twilight trial).
Q On the basis of so many randomized trials, do you foresee the DAPT duration to decrease for DES?
A. I would say that various trials of differing DAPT duration has given us two messages; 1) shortening DAPT to 6 mths for noncomplex PCI with second generation DES is ok, and 2) in complex PCIs and frequent CAD events pts at predicted low risk of bleeding, prolonged DAPT is beneficial.
Q Are DEB redundant for PCI or are there any niche indications left?
A. DCB will still have a role in focal DES ISR or in pts where DAPT duration is limited by their baseline medical conditions.
Q In 2015, with little use of Taxus, how does Tuxedo remain relevant?
A. I agree that Tuxedo trial results are not relevant in current scenario, as Paclitaxel coating has been accepted as the inferior anti-proliferative agent.

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