Questions / Answers
| Back to case | |
 |
|
|---|---|
 |
How many LMCA are you doing in a year? |
 |
Approximately 200/year. Majority of them have Syntax score of <33. |
|
|
|
Of these, how many are bifurcations LMCA? |
|
About 2/3rd (as has been reported in other LMCA PCI trials). |
|
|
|
How useful are you finding the SYNTAX score? |
|
Syntax score is very useful from angiographic lesion complexity point of view but it does not take into account of the pt's morbidity and hence we are analyzing the relative value of Syntax score with our NY State PCI score, trying to establish the predictive value of each score on ling term MACE. |
|
|
|
Are you using it for every multi-vessel intervention? |
|
Yes In our cath lab if pt does not have ACS or high medical morbidity (CVA, COPD, Age >80yrs) and Syntax score is >32, it automatically will require a consultation with the CT surgeon before proceeding for multivessel PCI. These pts are taken out of the cath room and discussion about various options takes place in the holding area with CT surgeon and the Interventionalist's (along with pt's family). |
|
|
|
Are you adhering to the SYNTAX score very rigidly? |
|
YES since Jan 2010. We have done the review of our PCI cases and we are >88% compliant (i.e. initial referral to CT surgery for suitable cases of Syntax score >32). |
|
|
|
What has taken a greater bite from the procedures going for surgery at
your institution - successfully treated CTO or LMCA? |
|
Both; in-fact successfully treated CTOs, since being more common than LMCA lesions, has higher negative impact on our CT surgery volume. But CABG volume is 12% higher YTD vs. 2009 at MSH, mainly due to adoption of Syntax score in our practice. |
|
|
|
What percentage of your LMCA needs IVUS? |
|
At present <10% but number is increasing. I also believe that IVUS may be useful in improving long-term results of LMCA PCI. |
|
|
|
Do you feel OCT will improve upon your ability to perform complex coronary interventions? |
|
believe OCT may be helpful in Bifurcation lesions. Main role of OCT will be in predicting if patient can safely come off the plavix (especially for non-cardiac surgery within 6-12mths of DES implantation). |
|
|
|
Is your use of FFR on the rise? |
|
YES, significantly. Now we are routinely using FFR in borderline/Intermediate lesions; perform PCI if FFR is <0.8 and defer PCI if it is >0.8. |
|
|
|
How has it impacted your IVUS use? |
|
In order to make appropriate decisions, the use of both technologies is increasing in our cath lab. |
|
|
|
Where are you finding the largest practical benefit of FFR? |
|
In bifurcation and LMCA lesions. |
|
|
|
Have you discovered disparities in your assessment of angiography after increasing FFR use? Are you sometimes surprised that the lesion is not physiologically severe despite obvious angiographic severe disease? |
|
Yes that is very common; lesion looks 70-80% but FFR is 0.9. Also in some borderline LMCA lesions of 50-60%, we have been surprised to see FFR of <0.8. |
|
|
|
How useful are you finding FFR for LMCA? |
|
Very useful as many times IVUS does not help while FFR does in making the decisions. |
|
|
|
What are some caveats in interpreting multi vessel disease with FFR? |
|
There should be no issues with multi-vessels but may be with multilesions as even moderate lesions, cumulatively may give rise to low FFR. |
|
|
|
How much time is FFR adding to each case? |
|
About 5 minutes. |
|
|
|
How much reimbursement does your institution obtain for FFR? And the physician? |
|
For the hospital if it is done with PCI, then it is bundled in DRG and no extra reimbursement. If done as stand alone without PCI, hospital gets about $700 (FFR wire costs $650). Physician payment is anywhere 120-150$ for the FFR as well as IVUS. |
|
|
|
Which is more user unfriendly - Rota wire or FFR wire? |
|
Both are difficult wires to manipulate, but Rotawire may still be more friendly. |
|
|
|
Intracoronary or intravenous use of Adenosine? |
|
IV adenosine is now preferred and being used routinely. |
|
|
|
Do you prefer second generation DES for LMCA? |
|
Yes with the exception of ostial LMCA, where first generation DES may be better due to their tensile strength. |
|
|
|
Prasugrel or Clopidogrel for your unprotected LMCA? |
|
If no contraindication, then Clopidogrel because of its reliable anti-platelet effect. |
|
|