CCC Live Cases
Questions / Answers from June 8, 2010 Case

Questions / Answers

Back to case
Do you feel that most cath labs should have a default strategy for a surgical opinion for a SYNTAX score >33?
I strongly believe in this strategy of CT surgery referral of pts with Syntax score of >33. This is evidence based by the fact that at 2-yr of F/U, there was a trend towards lower MI/death in high Syntax score pts who underwent CABG in comparison to Taxus PCI.

How many LMCA does your institution perform each year?
Approximately 200 ULM PCIs per year for last 3-4 yrs. This year, number has increased largely due to the fact that ULM PCI
is no longer in the class III group. Expected # of >250 ULM PCI by 2010 year end will make MSH as the leader in the USA
(perhaps only surpassed by Dr Park in Korea). But we still should have a collaborative strategy with CT surgery team in
approaching these ULM and high syntax score pts. This strategy will provide the best treatment option for these pts and also
will prevent any complications.

What is your work horse stent for these patients?
Largely Xience V stent for 2 reasons: low early/late/VLT stent thrombosis and extremely low TLR rates. Only caveat will be calcified ostial LM where I have observed some elastic recoil and failure to open the lesion fully with Xience V DES. In some of these cases, I have used Cypher DES inside the XienceV DES to provide extra tensile strength.

What is your IVUS recommendation for these case?
Left main PCI done with IVUS assistance has shown to improve outcomes in few selected series (Main-Compare trial). We still do not use IVUS routinely in our ULM cases at Sinai.
Is IVUS mandatory for ULM PCI as it has shown to reduce mortality in ULM stenting group?
I still think IVUS is preferred but not mandatory for ULM PCIs. This will be the practice in the EXCEL trial of ULM revascularization where IVUS post PCI will be encouraged but not mandated. I personally do not believe that routine IVUS use will reduce mortality after ULM PCI. The impact may be small in high volume operators who are tuned to make decisions by angiography. Also IVUS use for ULM PCI is a Class IIa indication (not Class I yet).
And for ablation?
Rotablation is reserved only for heavily calcified lesions.
How are you deciding the use of Rotational Atherectomy, Cutting Balloon or Angiosculpt?
We use following strategy: Severely calcified lesions- Rotational Atherectomy, mild-mod calcified lesions- Cutting balloon or Angiosculpt and ostial lesions- Cutting balloon. We found cutting balloon atherotomy yielding better results in ostial lesions compared to Angiosculpt.
Always 7F guide for these cases?
Yes 7Fr guide even if one stent strategy is opted as it causes less crisscrossing of the wires once kissing balloon inflations are done.
How much has the Impella contributed to the success of such cases?
Impella device has improved success in selected cases with low EF (<20%) by reducing the procedural complications and allowing optimal stenting strategy to be performed without concerns of the hemodynamic instability.
Have you had an age cut off for the Impella device?
No as we have done 2 cases- 91 and 93 yrs of age. For the PROTECT II trial upper age cut off is 90 yrs. Most important issue for these elderly pts, is Ileo-femoral tortuosity and calcification.
The Impella device appears such a user friendly device? Is there much of a learning curve to it?
Agree fully that Impella device is a very user friendly device with very little or no learning curve required for it's insertion.

How does the device perform financially for an institution?
Impella insertion is billed as the LV assist device with added medical co morbidities which puts into DRG based payment of close to 90K per case. This payments very well covers the $20000 Impella device cost. Also from the professional point of view we get added reimbursement of approx $1600 for device insertion and removal.

Do you find the Impella device useful for STEMI and shock/pre-shock?
Yes Impella device is a great adjunct tool for hemodynamically compromised STEMI including cardiogenic shock. We still need to get some more experience in this clinical scenario knowing that there will be no randomized trial for this application.

Has the Impella device impacted on the use of Tandem heart at your institution?
We have presented our data of Tandem Heart vs Impella and found Impella to be superior by virtue of lower device time and lower vascular complications, yet providing great hemodynamic support. We have not used Tandem Heart assistance for PCI in last 2 yrs at our center.
How many Impella cases are you averaging per month?
About 1.5-1.8 cases per month making 20-22 cases per year. This # is likely to change with the results of PROTECT II trial.

Where do you advocate removal of the Impella device?
As a general rule Impella device is removed in the cath lab after successful PCI. In rare cases device can be left for upto 3-5 days and then can be removed in the CCU.
Why do you think the Xience V is a particularly good stent for complex lesions such as these?
Major advantages are: easy delivery, less side branch closure, lower peri-procedural MI and lower stent thrombosis (subacute or late). This has been our experience and is now fully supported by emerging data from various trials: SPIRIT IV, SPIRIT V diabetic, COMPARE, and recently presented
XIENCE V USA registry.
What is your step wise inflation strategy using a Xience stent for SKS?
Start with 10atm for both, then individual inflation to 12-14atm for each and then fourth & final inflations at 10atm for both with simultaneous inflation and deflations.
What will be the duration of DAPT for this patient?
In this pt with severe LV dysfunction and additional untreated coronary lesions, DAPT will be recommended for lifelong. In other cases, our recommendation has been DAPT for 12-15mths.
Will you bring this patient back for an angiography?
Surveillance angiography after ULM PCI is no longer routine now (as per updated guidelines of Nov 2009). But cases like present case, we bring them back for angiography in 4-6months and at that time will also perform PCI of the residual lesions. In the EXCEL trial of LM revascularization, routine angiography is not indicated.
 
 

Back to case