Questions / Answers
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We heard Dr. Mehta congratulate Dr. Sharma. What is the basis of being selected for this recognition? |
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A recent report from NYS DOH of PCI cases from 2005-07, declared Mount Sinai Hospital cath lab as the safest cath lab in NY State with significantly lower then average (** status) 30-day risk-adjusted mortality (RAMR) of PCI. In addition Sinai was the only hospital having 2 of it's Interventionalists (Drs Sharma and Kini), also receiving the ** status of lower than average RAMR. We have received ** status of safety for Sinai in the past but never had both highest volume and the safest ranking before. Also Dr Sharma has received the ** status for 10 yrs in the past reports (from 1994-2003) and Dr Kini in 2006 report. |
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What do you attribute to your low complications? |
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High volume operators, Standardized medical protocols and strong QA process are the main ingredients of this remarkable success. |
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What percentage of these cases in the NY database constitute complex coronary interventions? |
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Approximately 15% largely due to CTOs, Bifurcation, Calcified, unprotected left main (ULM) and thrombotic lesions. |
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How do you define a case “complex” in 2010? |
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Precisely the cases I mentioned: CTO, Bifurcation, Ostial, Heavily calcified and Thrombotic lesions. At Sinai Calcified, bifurcation and ULM lesions make up the majority. |
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Did you consider CTS for this patient, including an off pump LIMA-LAD? |
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YES, if PCI will fail in two attempts, then off-pump mid-CAB LIMA to LAD will be appropriate. |
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What did your surgeon’s feel? When would they operate on such a case – with failed CTO attempt and persistence of symptoms? |
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YES. This case should get LIMA if PCI fails as pt has both symptoms and ischemia. |
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That is an excellent review of guide wires and guide wire strategy. What is your work horse guide wire for routine cases? |
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Runthrough NS (Terumo Inc) and BMW (Abbott Vascular Inc) are the workhorse wires in simple cases and Fielder (Abbott Inc) in the angulated cases. |
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And for CTO? |
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All guidewires are Abbott/Ashai manufacturers. Starting with Fielder FC for finding micro channels followed quickly by Cross-it 100 or MiracleBro 3 as second line wires. |
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What do you consider are the adverse predictors of CTO success, now that our methodology incorporates retrograde techniques? |
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Calcification and ostial occlusion with a blunt end are the 2 most important adverse factors. Calcified CTO lesions remain adverse even for Retrograde recanalization. |
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Always using Bivalirudin for CTO? |
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YES. As we have shown that it is quite safe as long as there is only wire perforation which will disappear in few minutes of stopping the Bivalirudin infusion. |
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Always a bilateral cannulation? |
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YES. Contra lateral injection really helps to better navigate the guide-wire distally. Also will limit the extent of distal wire passage in the false lumen. |
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Have you performed any CTO via radial routes? |
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YES. Limited numbers and should not be different then femoral approach for the radial experts. |
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Would a CT angiogram be useful in this situation? |
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Many operators are using the CTA for these complex CTOs to direct the wire passage and assess the distal tortuosity. It may also help to see the atheroma burden. |
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IVUS? |
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YES. IVUS could be useful to find the entry port and to see if guidewire is in true vs false lumen. |
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What do you feel contributes most to the success in a CTO – guiding catheter, support catheter or guide wire? |
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In my opinion, it's all in the guidewires (about 80%) with guide catheter and support catheter contributing approximately 10% each. |
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How much time will you not exceed for a CTO and how much dye? |
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Three hours of the cath lab time, 100 minutes of Fluoroscopy time and 500 cc of the contrast volume are our recommended usual upper limits. |
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If you are unsuccessful in crossing a CTO, are you finished or you will bring back for a second procedure? |
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Absolutely YES in 4-8 weeks later. Rare cases of extensive intimal dissections or free perforations are exempt from this routine second try strategy. |
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Are there insurance challenges in bringing these patients back – of course, there are advantages such as avoiding CTS and patient preference, but insurance companies do not necessarily see it this way? |
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It could be problematic if indication to do CTO was not appropriate initially but not an issue if indication was appropriate because a successful procedure will likely eliminate the need for CABG. We as interventionalists should use sound clinical judgment for appropriateness of CTO recanalization (as per the appropriateness criteria) and should refrain ourselves from the 'oculo-stenotic reflex'. |
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Enumerate your guide wire escalation strategy for us? |
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Starting with MiracleBro 3 or Cross it-100 and then Confianza 9 or MiracleBro 6-9 and finally ending with Confianza Pro 12. We are now gaining the experience with new guidewires from Abbott (Progress family) for these tough lesions. |
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Do you feel cath labs need a dedicated CTO operator? |
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Not for all cases but for tough CTOs especially for the second try. |
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