Questions / Answers from December 21, 2010 Case
Questions / Answers
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The patient has surgery written all over his presentation? What do you feel? |
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Yes. I agree somewhat and we need to convey the correct message to the patient and family based on the available data (high Syntax score pts after CABG, live longer and have lower MI at 3 yrs follow-up). Many times pts still decides for PCI even in these cases despite careful discussion and that is exactly what transpired in this case; pt wanted PCI and No CABG. Again these discussion have to take place outside the cath room; not while pt is lying on the cath table. |
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Did you consider FFR guidance here or you are clinically and angiographically convinced that both the LAD and RCA need to be treated? |
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Yes. FFR usually guides us in 50-70% lesions to evaluate the hemodynamic significance; but this pt has close to 90% lesions in both LAD and RCA and decision was made to do PCI by angiogram only (without FFR or IVUS). |
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Between the LAD and the RCA, the live case notwithstanding, which vessel should be treated first? |
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We always try to work on the most important vessel first; which is the LAD in this case. Main reason behind this approach is to avoid incidental closure of the major vessel causing cardiovascular catastrophe during hemodynamic shifts, if occurs during PCI of the less important vessel. |
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Between PTCA of the side branch to a two stent DES strategy, what do you prefer? |
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Again this field is still very controversial and majority recommends PTCA of the side branch and use stent only for suboptimal results. But in some cases, I prefer planned 2 stent strategy such as angulated or long lesions in the large side branch (>2.75mm). |
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What is your optimal duration for waiting in staged PCI procedures? Why? |
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It is usually one month and gives enough time for the pt to recover and also puncture sites to heal well. Also it avoids the issues of early stent thrombosis which usually occurs in first month. |
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What percentage of your procedures are same-day discharge? Do you have strategies built for that such as doing these cases early in the morning? |
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Currently, 40% of the cases are same discharge; 8-10 cases per day. We have the system and observation unit which can safely allow pts to go home even by 11pm or midnight. |
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How long are you continuing Bivalirudin post PCI? Is this strategy different for STEMI? |
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In Clopidogrel naive pts, we continue Bivalirudin infusion for one hour post PCI, allowing Clopidogrel load to attain it's peak effect (120 minutes). Bivalirudin half life is 25minutes and hence stopping it one hour after PCI allows full platelet inhibition to come in play by Clopidogrel preload. |
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How much is the use of Prasugrel in your laboratory? In what situations are you finding it more useful? |
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At present we are still very cautious with this very potent agent and use prasugrel in about 25-30% of PCI cases; especially Diabetics, STEMI and Clopidogrel non-responders. |
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For what patient subsets are you using Platelet Aggregometry? Or, is it already routine at your institution? What cut off values are you using? |
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We are using Verify Now assay of platelet aggregation inhibition by Accumetrics device especially in cases |
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We are also impressed with the image resolution of OCT, yet, there are technical issues? Do you feel it is ready for Prime Time and what do you think are its top 3 indications? |
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Clearly technical issues will be overcome by experience and increasing use of the machine and the catheters. I think OCT will take its place in Interventional cardiology in selected cases; 1) detection of vulnerable plaque, 2) stent expansion and 3) evaluation of DES endothelization especially in pts requiring DAPT interruption. |
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