Q&A
Q.
Which was the most instructive live case during your 28th annual symposium?
A.
I will say the most instructive and learning case was the first of the cccsymposium case involving calcified LAD/ Diagonal bifurcation case with Impella assist done by Dr Kini. The steps of Rota in uncrossable angulated mid LAD lesion were emphasized along with the steps of MiniCrush Stenting with IVUS imaging. This case also had mid D1 stent perforation requiring covered stent.
Q.
Can these live cases be reviewed?
A.
Yes all these live cases are available at the ccclivecases webcast site.
Q.
Was there any different take home message from the live cases, different than ccclive cases?
A.
Actually both CCCsymposia and ccclivecases have a similar unified message, that is to demonstrate the appropriateness and performance of the technical aspect of a complex case without any industry bias but with a big touch of personal experience.
I am glad to report that we have a big following to our concept as shown by increasing attendance of cccsympia (532 participant this year vs 446 last year) and ever increasing viewers of the live webcast (now 23000+ every month). These are very satisfying and encouraging to me whose mission all the life was to teach and educate people to improve their personal and professional performances.
Q.
Can one claim CME still for the archived ccclive cases? Is it a difficult process? Is there a cost?
A.
Starting this month we will have CME for archived cases and there is no cost to it. Process remains the same and very simple, to log in to see the case and then generate the CME certificate by going to the website link provided.
Q.
What is your position on the 2025 STEMI guidelines regarding imaging?
A.
As per the recent ACC guidelines, imaging (both IVUS and OCT) got the class I indication. Hence will strongly recommend imaging during STEMI PCI. I also strongly recommend to do imaging in the end after the final angiographic results as it’s pre procedure utility is very limited.
Q.
With so many EuroPCR publications on optimal management of calcified lesions, has your strategy changed?
A.
Actually, most of the trials presented in EuroPCR have endorsed our published algorithm for the management of the heavily calcified lesions;
- Most of these lesions (>80%) can well be treated with high pressure NC balloon and should be the initial strategy
- RA is essential in complex difficult lesions and has high procedural success with perforation rate of about 1-2%
- OA does not have any advantage in these lesions with higher slow flow and perforation rate of about 2%
- IVL is the best device once crosses the lesion with higher calcium fractures and very low perforation rates <0.5%
- ELCA is inferior to other Ca++ modifying devices
Q.
What was the turning point in today's excellent case and its outstanding result?
A.
Again persistence and step by step approach in treating a complex bifurcation lesion by wire escalation was the key. In the angulated Diagonal, we were able to wire after dilating the main LAD lesion with high pressure balloon and Cutting balloon.
Q.
Did you end up using Gp2b3a therapy or Cangelor for the case?
A.
We did not use either GPI or IV Cangrelor in our case as pt did well with no residual chest pain in the end. Also pt is >80hrs of age where we try to avoid these agents and just use clopidogrel and avoid strong P2Y12 inhibitors.
Q.
How are you deciding which patients to use a larger dose of Prasugrel?
A.
We use Prasugrel 10 mg (after the loading dose of 60mg in all cases), in pts with 3 or more stents and weight >100Kg. These data are based on our initial PRU measurements when we started using 5mg prasugrel routinely (2013-14). We have published this in JACC CVI paper and had no mishaps in our practice at present. Certainly this strategy has reduced the major bleeding in our pts which was common after 10mg Prasugrel daily dose.
Q.
For your routine stable CAD patients, what is your duration of DAPT?
A.
For stable CCS cases, we are still giving 1Yr of DAPT in majority but have very low threshold of making it 6M if bleeding is an issue. We use Ticagrelor (30-40%) or Prasugrel (60-70%) in about 1/3rd of these stable CCD PCIs due to the lesion complexity.
