Complex coronary cases
Unstable Complex LCx CTO Bifurcation Intervention – May 2020

Case and Plan:

50-year-old male on HD, extensive CAD presented with progressive CCS Class II angina and high risk SPECT MPI for multivessel ischemia as preop for renal transplantation. A Cardiac Cath on December 2, 2019 revealed 3 V CAD: 95% LCx bifurcation with CTO ISR of OM1 (Medina 1,1,1), FFR+ 60% mid LAD/D2 bifurcation (Medina 0,1,1), CTO ISR of mid RCA with LVEF = 55% and SYNTAX Score of 39. In view of multiple DES CTO ISR and CAD progression, patient was recommended to undergo CABG pre renal transplantation. After Heart Team discussion, patient declined CABG and placed on maximal medical therapy. Pt continued to be symptomatic despite maximal tolerated MT and is now planned for high risk intervention of LCx/OM1 bifurcation and to stage RCA/LAD intervention after one month.

Q&A
Q
Regarding STEMI, have you used any lytics in the last month?
A.

Not lyrics for STEMI at all yet at Sinai. Now we have changed the protocol to do PPCI even in Covid-19 STEMI cases.


Q
In which cases will you use lytics with the present information?
A.

Only in transfer cases, where system delay (due to unavailability of ambulance or staff) is perceived to be more then 2-3 hrs; which is very unlikely.


Q
So, should one do the Rapid test or not?
A.

I suggest not to use the current Abbott’s Rapid Covid-19 test as it can be false negative in 30-40% of cases.


Q
Or, rely solely on a better history?
A.

History of Covid exposure and symptoms are also not fully reliable and can be negative in 1/3rd. Chest Xray has 90% sensitivity and CT chest has 98% sensitivity. Hence we still have to resort to a better Covid-19 test.


Q
Or, get a CTA?
A.

CT chest is very sensitive and specific.


Q
Any difference in how you approach the Primary PCI procedure?
A.

Yes Impella will be appropriate in STEMI PCIs with severe LV dysfunction especially in non-Covid pts. In Covid pts, Impella use in this scenario has to be very judicious to minimize the potential staff exposure to the virus.


Q
With severe LV dysfunction and STEMI, does Impella make sense?
A.

Yes Impella will be appropriate in STEMI PCIs with severe LV dysfunction especially in non-Covid pts. In Covid pts, Impella use in this scenario has to be very judicious to minimize the potential staff exposure to the virus.


Q
Or IABP?
A.

Same statement will be true for IABP use also just like Impella recommendations.


Q
What is your commonest DES presently?
A.

At Sinai we have 2 DES product rule; currently Xience and Synergy only.


Q
Among the lifestyle modifications that you mentioned, is there one you feel is the most beneficial?
A.

Mental and physical relaxation now and even in post Covid era is the most beneficial lifestyle modification to minimize the impact of CAD.


comments

Join the Discussion

2 thoughts on “Unstable Complex LCx CTO Bifurcation Intervention – May 2020”

  1. Nayef says:

    Ppt is not working there is problems in downloading

    1. Hi Nayef,

      We tested the download link in a few browsers and it seems to be working on our end. Can you check to make sure that you don’t have firewall issues on your end. Thanks.


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 295

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 […]