Questions / Answers
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This is a complex procedure. Would you let your fellows do this case? |
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Depending on the training of the fellows, these complex lesions can be safely done by the Interventional fellows. Of course we always be scrubbed in the case. |
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How many Primary PCI do your fellows get to do by the time they are finished with their training? |
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We do about 150-180 primary PCIs (in <24hrs) per year and is divided amongst 7-8 Interventional fellows (about 20 STEMI PCIs/fellow/yr). |
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Notwithstanding the recommendations, what is the appropriate number of PCI procedures that a fellow should perform? |
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In my opinion, once an Interventional fellow has actively participated in performance of 500 cases, he/she has good understanding of the complex cases and able to make appropriate choices. |
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What all should that include - simple versus complex PCI? |
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Yes all total 500 cases. Complex cases are usually 25-30% of them, defined as CTO, Thrombotic, calcified, bifurcation, aorto-ostial and SVG lesions. |
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It was good to hear your update on DES? What do you feel has been the biggest advancement in PCI for 2009? |
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In my opinion biggest advancement in 2009 is that Left main PCI has been incorporated in the main stream of Interventional cardiology and no longer is Class III, as per recent focused update. |
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What are the advantages for the Xience V? |
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Besides easy delivery, less Sidebranch closure, easy side branch access and easy conformability to vessel shape are the additional advantages of Xience V DES. |
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Where will you not use a Xience stent? |
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Cases of calcific aorto-ostial disease especially LM ostium. We are still developing experience for Xience V use in non-LM bifurcation lesions. It is great for LM bifurcation lesions whether one or two stents technique is used. |
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How much DAPT are you suggesting, for the Xience platform, and for other DES? |
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For Xience DAPT doe 12 months and taper in 13-14th month by making plavix every other day, before stopping completely to avoid any rebound. we now have 1000 cases where Xience V has been discontinued after 12-14 mths without any late thrombosis. In rare cases of >4 DES or LM Xience V DES, we are empirically continuing DAPT for 2 years. Same is true for Endeavor DES (1 year of DAPT). For Cypher and Taxus we routinely recommend DAPT for 3 years. |
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What stents would you suggest for STEMI Interventions? |
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I personally believe, if compliance is not the issue, DES is OK in STEMI. We have learnt this from HORIZONS-MI trial and other DES trials in STEMI. No increase stent thrombosis with DES vs. BMS. |
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Would you use a Xience stent for STEMI? |
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YES as long as we know patient is going to take plavix for one year. |
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Since this patient has renal dysfunction, would you object to anyone doing this case without Rotational Atherectomy - all operators do not have your expertise in this device? |
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Rotational atherectomy is done "ONLY" for heavily calcified lesions which this patient had and hence is essential. Rare cases can also be done using high pressure balloon dilatation or Cutting balloon but could have higher dissection. |
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Why not do T stenting in this case? |
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That will be another approach but will requires recrossing and kissing balloon inflation. SKS technique can obviate all those steps. |
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Can you give your recommendations about SKS, T or V stenting? |
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Yes. SKS for large side branch and short proximal disease before the carina. V technique is like SKS with <2mm proximal overlap if no pre-bifurcation lesion is present. T stent technique will be good for small side branch which has dissection after PTCA and there is also disease in the main vessel. |
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Is a Medina classification a must essential before deciding this strategy? |
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Not really. But you need to have clear cut planned strategy for bifurcation treatment. |
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How much of the Syntax score are you applying in your clinical practice? |
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Routinely now and pts with high Syntax score >32 and no contra-indication to CABG, initial recommendation for CABG is being made in these pts. |
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Besides RA what can you use in treating such a case, so as to limit the dye? |
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Not too many choices are available in these cases except trying high pressure balloon inflations (and keep another wire in the vessel; poor man's cutting balloon) |
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What are your recommendations for treating patients with renal dysfunction? |
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Most important is limit contrast load. Mucomyst is routinely given. Soda-bi-carb has come of the favor as we have had few cases developing pulmonary edema with its use. |
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Sodium Bicarbonate therapy is dead? |
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YES for all practical purposes. |
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Which dye? |
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Non-ionic low-osmolar dye is routine (except Omnipaque). No need for expansive iso-osmolar agent (Visipaque). |
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What is your limit to the volume of radio contrast agent for these cases? Does a nephrologist always clear your patients? |
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Contrast Limit is "As little as possible" but <100cc is the usual limit. Nephrologists see the patient if they are post-transplant or Serum Creatinine rises next day. |
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Do you feel that Xience stent grows more than you expect? |
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Yes at the edges and hence keep low deployment pressures and post dilate within the stent segment. |
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To me this LAD/D1 lesion seems to be Medina 0.1.1. Would T-Stenting not be the preferred technique to cover the SB ostium instead of V-Stenting? |
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Not really as V stenting will be preferred in 0.1.1 Medina classification because it will cover both distal MV and sidebranch lesion well. T Stenting will require recrossing and later kissing balloon inflations. |
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