Complex coronary cases
Ostial LAD CTO PCI via Retrograde Approach – March 2020


 

Case and Plan:

52-year-old male with COPD and OSA presented on January 31, 2020 with acute hypercarbic respiratory failure requiring intubation and ruled in with peak Troponin of 12 (Type 2 MI) and acute systolic heart failure NYHA Class IV. Patient was stabilized on medical therapy and extubated. A Cardiac Cath on February 3, 2020 revealed 1 V CAD: flush long total occlusion of ostial LAD with excellent collaterals from RCA and LVEF 48%. Patient was managed medically due to multiple medical and psychiatric issues. Patient has been compliant with GDMT with CCS Class II angina. A followup stress MPI revealed large area of severe anterior wall ischemia with partial scarring. Patient is now planned for PCI of ostial LAD CTO via retrograde approach from RCA collaterals.

Q&A
Q
Can we infer that the interventional cardiologists were correct in the EXCEL debate?
A.

Yes for the the controversial topic of observed higher 5-year mortality after PCI in the Excel trial, the recent meta-analysis of 5 RCTs with 1-5 years of f/u has shown similar mortality after PCI and CABG. Hence it is appropriate to say that Interventionalists were correct in the EXCEL debate.


Q
Is the biggest take home message similar mortality rates?
A.

Yes it is a very important message that both PCI and CABG have similar mortality in low-intermediate Syntax risk pts (Syntax score <33). This observation will be very important for the PCI update guideline writing committee.


Q
Would this data affect guidelines?
A.

I expect these LM PCI outcome observations will favorably influence the guidelines writing committee to make PCI as a viable alternative to CABG for the treatment of less complex LM CAD.


Q
Should most non Type 1 AMI have a diagnostic catheterization?
A.

Yes as shown in the reports as well as our own experience at Sinai, 65-70% of type 2 MI have significant CAD and treating it appropriately may improve their prognosis. Cath is recommended in thsese semi-elective setting rather then urgent setting after the primary event cools down. Cath is not recommended in cases of myocardial injury as it is more of a myocardial process rather then CAD. More important part of the management of type 2 MI should include appropriate MT similar to type 1 MI. I hope these aggressive strategic measures will improve type 2 MI favorably. We have set a predefined protocol on those lines to treat Type 2 MI at MSH with a dedicated interventionalist and a NP to manage these pts in non-cardiolgy units.


Q
Clearly the Type 2 AMI also explains the atypical presentation in women?
A.

Yes presentation of Type 2 MI may be very atypical in both men and women but will have some underlying illness and predisposing factor causing supply/demand mismatch along with rise and fall of Troponin.


Q
Why do you like the Gaia wire?
A.

We like Gaia wire because of their 1:1 torqueability, hydrophilic coating, differential penetration power (Gaia 2; 0.011” tip and 3.5gm penetration power , Gaia 3; 0.012” tip and 4.5gm penetration power) and ability to remain in the lumen. another key to use these wires is not to over torque and wait few seconds after each movement as ropecoil design tip will find the way into true lumen or pierce the tough CTO cap.


Q
What are the changes between earlier and the new Gaia 3?
A.

We actually have only first generation of Gaia 2 and Gaia 3 series. The Gaia 3 has 4.5gm top and 0.012” tip and is ideal for CTO recanalization.


Q
What percentage of your CTO are using the R femoral, L radial strategy?
A.

Approximately 70% of CTOs are done using Rt femoral (working guide) and Lt radial (for retrograde collaterals) in our cath lab. Bilateral femorals are used in 26-28% of cases and bilateral radials in <5% of CTO cases.


Q
Even for retrograde approach?
A.

For planned rare retrograde approach, most (>95%) are done using both femorals and rarely combination of Rt femoral and Lt radial.


Q
What was the key reason for success in today’s procedure?
A.

Persistence and recognizing early that Gaia 3 has gone subintimal and then quickly escalate to Confianza 9 guidewire.


comments

Join the Discussion

12 thoughts on “Ostial LAD CTO PCI via Retrograde Approach – March 2020”

  1. Basem Enany says:

    Dear all
    I can.t see the webcast

  2. Rameshwar Bishnoi says:

    regularly follow up live cases

  3. Rameshwar Bishnoi says:

    In psychiatric patient compliance of drugs remains a big challenge.Do you think post PCI in such complex case compliance makes you little worry.

  4. Shmuel Shapira MD says:

    I can not view the case

  5. anas says:

    how can i see it

  6. Ashish says:

    The file is not available

  7. Suresh Sharma says:

    I can only see the case description but no video link to the case.

  8. Tanvir Ahmad says:

    very useful

  9. ΠΑΝΑΓΙΩΤΗΣ ΠΕΤΡΟΠΟΥΛΑΚΗΣ says:

    WHERE IS THE VIDEO

  10. surender kumar md says:

    good

  11. yolandi says:

    still no youtube video on this case?

  12. Arthur Calick says:

    Could not download archived case


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, https://ccclivecases.org. 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

suggestion
Suggestions
Staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and IVBT – November 2020
Views 297

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 356

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 281

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 […]


Stent Ablation with RA of Underexpanded Multilayer DES – August 2020
Tags: | |
Views 448

63 year-old male with known CAD, CABG x2 (1999) and multiple PCI’s to SVG to RCA and LCx branches presented with CCS Class IV angina and non-STEMI (TnI 1.2U). A Cardiac Cath on June 22, 2020 revealed patent LIMA to LAD, non obstructive LCx branches with patent prior stents and 90% multilayer in-stent restenosis of […]