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Questions / Answers from November 17, 2009 Case

Questions / Answers

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If this patient was a 60 year old, would you then have considered surgery for her?
Yes in this patient because of extensive calcification and diffuse disease of LAD and distal LM bifurcation, CABG will be the correct choice irrespective of the age. Definitely more so in a young patient.
What is the status of cardiac surgery at your institution - the volumes?
We do about 400-450 CABG and about 700 other cardiac surgery bringing an annual volume of about 1100 cases. Total Interventional volume has been over 5300 every year (4700 PCIs, 500PTAs and 100 Valvuloplasties).
What are your indications for referring a patient in 2010 for coronary bypass surgery?
Pts with bifurcation LM disease, multi vessel disease with >1CTO (with low chance of opening), extensive multivessel diabetics (syntax score >33) and recurrent DES, in my opinion are the appropriate cases for CABG. LVEF is no longer the criteria of referring pt for CABG as PCI will have lower morbidity and short-term mortality in these cases.
How useful are you finding the SYNTAX score in your practice?
We are just trying to understand the role of SYNTAX score in our day-to-day functioning. We know well that in the SYNTAX trial, score was predictive of f/u MACCE but important limitation is that it does not account for overall patient condition such as CVA, PVD, LVEF, CHF, CKD which all independently have shown to affect MACCE especially survival. Presently
we are not using SYNTAX score in our day-to-day decision making process but soon will integral part of our cath lab reporting.
Are you able to share some preliminary results from FREEDOM?
What we know that at midterm point of 1000 patients enrolled and 1.8yrs of mean f/u, DSMB analyzed the data and recommended to continue the trial. In my opinion, that was a great relief that PCI atleast was not significantly inferior to CABG at midterm follow-up.
If you did not have Rotational Atherectomy available to you or you did not find yourself competent in performing RA, would you then attempt this case?
NO. This case can't be done without Rotational atherectomy as even 1.5/6mm Sprinter balloon could not cross the mid LAD subtotal heavily calcified lesion.
What is the role of IVUS in such cases?
Not in this apparent calcified case but yes in some chronic lesion, IVUS may be helpful in deciding whether Rota should be used if >270 degree arc of Ca is present.
How are you seeing the different roles for Volcano and for the BSC IVUS?
We actually have 4 iLAB and 2 Volcano systems in our cath lab. We use more Volcano IVUS in PTAs and routinely BSC IVUS in PCIs. I personally like the IVUS images of iLAB rather then Volcano.
What is your workhorse DES? Why?
XienceV is our workhorse DES in about 85% of cases because of it's outstanding performance of superior deliverability (>98% of cases), less side branch closure (<1.2%), less CK-MB release (<3%), low stent thrombosis upto 1 year (<0.2%) and very low TLR (about 3% in all comers). Also we are prescribing plavix for one year only with Xience V DES,
in contrast to 3 years for Cypher or Taxus (due to fear of very late stent thrombosis).
What are the special attributes of the Xience V and elaborate on post-deployment strategy?
Easy deliverability and less side branch closure are the main attributes of XienceV DES. Also Xience V stent balloon is a very compliant balloon and is deployed at 8-12 atm and routinely post dilate with high pressure non-compliant balloon at 16-24atm. My favorite non-compliant balloon is NC Voyager 20mm. This strategy has completely eliminated the edge dissection we used to see infrequently after Xience V DES when we started using it last year (and deploying it at pressures similar to our earlier DES 16-20atms).
 Where do you use the Cypher stent now?  Any role left for it?
For ostial LM and some bifurcation lesions. Also when lesion length is about 28-30mm, then one 33mm Cypher can cover it easily rather then using 2 Xience V DES.
Any concerns with Cypher stent fracture in the left main due to strong vasomotion?
Cypher DES has shown to have higher stent fracture especially in RCA. In LMCA we have not seen any stent fracture yet but could happen due to vasomotion.
What is your experience at MSMC with the Radial approach?
Use of radial approach at MSMC is about 7% of cases. One of our interventionalist perform all his 200 PCIs via radial approach. I agree that Radial approach is a great technique and one which really leads to significantly lower bleeding. But drawbacks are more x-ray exposure and extra time it takes in some difficult cases. Nevertheless it has an important role
in obese pts, in pts with PVD or in pts who are at high risk of bleeding (hematological abn, high INR).
What has been your Prasugrel experience?  Where do you see its main indication?
We have limited experience of Prasugrel use in about 80 PCI cases so far (selective use).I see it's use routinely in STEMI pts and plavix unresponsive/allergic pts. Clearly will not be used in three subgroups of <60Kg, >75yrs age or prior CVA.
How much will be the duration of anti-platelet therapy in this patient?
One year because of advanced age but in younger pts could make it a point of giving plavix for 3yrs even with Xience V DES. With Cypher and Taxus DES, we have been routinely prescribing plavix for 3 years.
Mandatory surveillance angiography? When?
Yes in all LM stent cases, we schedule for a f/u cath at 4-6 months, depending on if other severe lesion has been left untreated (4mths) and if no residual lesion left then 6 months. If there is even mild restenosis, then another f/u cath at 1 year is arranged but if no restenosis at 4-6 months cath, then further f/u is done only clinically.
Are you routinely using platelet aggregation studies in your lab? In what situations do you see its role?
Yes we use Accumetric device for assessing platelet aggregation especially to assess plavix responsiveness. We use it selected high risk cases such as LM stent, proximal bifurcation lesions and cases of DES thrombosis on plavix. With use of Prasugrel, I see the aggregation study to be used less and less because of its reported consistent and dependable efficacy. It a GP IIb/IIIa inhibitor is used then, pt needs to come back as an outpatient to the cath lab for Acuumetrics testing.
Incomplete stent /balloon expansion secondary to extensive adventitial (non intimal) calcification. How to diagnose and manage?
Superficial lesion calcium can only be diagnosed by IVUS and could be treated by just balloon dilatation and no need for Rotational atherectomy.

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