Complex Coronary Live Cases

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Questions / Answers from October 19, 2010 Case

Questions / Answers


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	One can argue for medical management for this elderly patient, after the STEMI intervention of the culprit lesion?
	This case is different then other non-culprit post STEMI lesion by being the unprotected left main lesion. Numerous reports have documented 15-18% annual mortality of medically managed LM lesions. Hence to be aggressive for revascularization (PCI or CABG) even in this elderly patient who is otherwise functional, with significant LM lesion is appropriate.

	So far as PCI is concerned, do you have an age cut off for an “elderly patient”?
	NO as long pts are mentally ok.

	What are some broad areas to monitor when performing PCI for elderly patients?
	Most important being vascular complications and contrast induced renal damage.

	What are your specific recommendation for managing renal function for these patients?
	Adequate hydration before and after PCI (oral or IV) and not keeping them NPO for more than 3-4hrs.

	How extensive has been your experience in stenting unprotected LMCA for elderly patients?
	Approximately 50% of the LM cases are above 80yrs of age and hence roughly 100 pts over the age of 80yrs every year getting LM PCI at Mount Sinai Hospital.

	There was some confusion about the minimum luminal area for LMCA during the discussion? Can you clarify?
	That is true because in contrast to epicardial vessel lumen CSA cut-off of >4mm2 for significance, we don't have a clear cut number for LM minimal lumen CSA. It is proposed to be >5.5mm2 in most of the studies. Although some reports have incorporated 6-6.5mm2 as the cutoff. Post stenting stent lumen CSA of >8.5mm2 has shown to be predictor of better long-term outcomes after LM stenting (BMS or DES).

	Are there situations where you will performing unprotected LMCA stenting with a BMS?
	Yes if pt can't take DAPT for minimum of one year. In these cases, every effort should be made for referring pts to CABG but in prohibitive surgical risk, BMS can be used. Usual case is a pt with prior CVA (or bad COPD) requiring major abdominal surgery and can't wait for 1 year after LM stenting; this case will be appropriate for LM BMS and then refer for non-cardiac surgery after 2-4 weeks.

	Can you offer guidelines for Rotational Ablation, CBA and Angiosculpt for plaque modification in unprotected LMCA?
	Rotational atherectomy for heavily calcified lesions; Cutting balloon for none to mildly calcific ostial LM or focal distal branch lesions; Angiosculpt use similar to cutting balloon with addition of moderately calcific and long lesions.

	In experienced hands, how often truly does IVUS alter your decision that is customarily guided by years of angiography guidance?
	In <5% of cases. This may largely because we have trained our eyes for optimal angiographic results and in some cases use 'Stent boost' as the poor man's IVUS.

	Do you think Prasugrel can be a better drug for unprotected LMCA?
	Absolutely agree as long pt is not high risk for bleeding such as prior CVA, old age >75yrs or underweight <60kg. Majority of these pts will get 60mg loading dose and 5mg maintenance dose of prasugrel in our lab. This strategy has reduced the bleeding complications significantly without increasing any ischemic event or stent thrombosis. We have tested over 200 pts for platelet-aggregation inhibition (reported as platelet reaction unit PRU) by Verify Now assay on prasugrel 5mg maintenance dose and in all except 2, we found PRU of more then 235 (our minimum cutoff value). I will recommend 10mg dose routinely to an obese pt (weight >125kg) or use of >3 stents or if PRU is >235 on prasugrel 5mg maintenance dose.

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