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.
Q In 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.
Q Which one will you find most useful here?
A. IVUS particularly for stent optimization; that is what we did.
Q For 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.
Q In 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.
Q Not 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.
Q For 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.
Q Which 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.
Q In 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.
Q Which 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.
Q What 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.