Case: 68-year old male with prior PCI’s in 1999, has crescendo angina and high risk stress MPI for multi-vessel ischemia. Cardiac cath revealed calcified distal left main with circumflex disease (Syntax Score 16) and moderate LV dysfunction (LVEF 40%). Now planned for PCI of unprotected left main coronary artery.
QIn this particular case with unprotected LMCA, where do you see the roles for IVUS, FFR and OCT?
A.IVUS is better suited for post DES optimization; FFR for ambiguous intermediate lesions; OCT as a research tool only.
QWhich one will you find most useful here?
A.IVUS particularly for stent optimization; that is what we did.
QFor low SYNTAX, is PCI your first choice at your institution? What % of your PCI are unprotected LMCA?
A.Yes for Syntax score <33 PCI is our first choice and we even do not call our CT surgeons for consultation. If Syntax score >32, then a CT surgery consultation is must and if pt still refuses, then only PCI can be contemplated. Yes there are some exceptions to this policy such as AMI, severe COPD , age >80yrs and h/o CVA. Unprotected LM PCI cases now are about 25 of 425 PCIs (approx. 6%) per month.
QIn what % unprotected vLMCA are you using IVUS and in what particular situations?
A.We use IVUS in about 20% of Unprotected LM PCI; especially in cases of haziness and r/o any edge dissections.
QNot using a support device these days for unsupported LMCA?
A.About 8-10% of Unprotected LM PCIs are done with support device; especially one with LVEF <25% and one requiring Rotational atherectomy.
QFor unprotected LMCA, should platelet reactivity studies be always performed?
A.Makes perfect sense to know that platelet inhibition if optimal in these high risk cases especially if on Clopidogrel. I do check platelet reactivity in unprotected LM DES cases and then tailor the antiplatelet therapy based on the PRU data.
QWhich anti-platelet will you prefer for unprotected LMCA – Clopidogrel, Prasugrel or Ticagrelor? Why?
A.If age/CVA are not the issues, I will prefer 5mg daily dose of prasugrel; because of its reliable consistent platelet inhibition. We don’t have experience with Ticagrelor yet, but I guess it could a preferred agent in cases with high risk for bleeding.
QIn your elective PCI, are you always using high dose statins?
A.Not routinely but data do support giving Atorvastatin 80 mg 12-24hrs prior to elective PCI in reducing the post-procedure MI. This has been incorporated in the EXCEL trial of Left main Intervention.
QWhich DES are you finding particularly beneficial for LMCA?
A.Now EES type DES of Xience V or Promus is the preferred DES for uLM PCI.
QWhat do you feel will be the most critical message from the EXCEL trial?
A.To show that DES PCI will be as good as CABG or may even has a chance to be better, in low-intermediate Syntax score.