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.


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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.


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