Q&A
Q.
Why did you prefer Orbital Atherectomy (OA) in today's procedure?
A.
Actually today’s lesion was appropriate for both OA as well as RA (Rotational atherectomy) because being a straight segmental heavily calcified lesion. We used OA for the teaching purpose as mostly we do RA in these lesions.
Q.
Why select it over Rotational Ablation?
A.
As I explained both OA and RA are optimal for today’s lesion while we recommend OA in straight less tortuous lesions severely calcified lesions and RA in subtotal long calcified lesions.
Q.
How do the costs of the two ablative therapies compare?
A.
RA cost is $2000 and OA cost is $2700; hence OA is higher but reimbursement is the same for both devices.
Q.
How does the cost of Orbital Atherectomy compare with the cost of IVL.
A.
IVL cost $4700 while OA is $2700 and RA is $2000. IVL has the higher add on device payment and gets higher reimbursement.
Q.
Please elaborate on your statement that "IVL is the second burr"
A.
As we know bigger the Rota burr, higher are the complications of slow flow, dissection and perforation and IVL has lower procedural complications. Hence after initial RA burr, IVL will cross and will be effective to complete the job of calcium modification with lower complications. This, in my opinion is a very synergistic approach and we have been advocating making statement that IVL as the 2nd Rotaburr.
Q.
Should the use of ablative devices be mandated by imaging?
A.
As far as Imaging mandate with ablative devices is concerned, IVI is recommended but not mandatory in these calcified cases. This statement is fully supported by the IVUS-CHIP trial; in which IVUS use was not superior to angio PCI in complex cases.
Q.
Any imaging, or OCT preferred?
A.
In calcified lesions, theoretically OCT gives better data then IVUS but IVUS is more commonly done for the ease and convenience.
Q.
How much do the recent trials regarding Orbital Atherectomy influence your decisions?
A.
In fact negative Eclipse trial has markedly reduced our OA numbers from 8-10 per month to 1-3 per month now. Hence trial results had an important negative impact in OA use; similar data across the country of OA use decline.
Q.
What are the clinical implications of the Yellow trials?
A.
Yellow trials have a similar and simple message that to stabilize the plaque, LDL in PCI pts should be around 40-50mg/dL and about 20% of pts are non responders to statins and PCSK9-inh. In these pts non statin or non PCSK9inhibitor may be useful (such Ezetamibe, Bampodeic acid).
Q.
How does the new oral PCSK9-inhibitor agent from Merck affect the Yellow trials and lipid management in general?
A.
New oral PCSK-inhibitor will improve medication compliance and will make easier to achieve ideal LDL levels. Hence it’s a great addition in the field of lipid management.
