Dr. MS Hiremath | A Case Only Intervention Could Solve | TheRightDoctors
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Dr. MS Hiremath : A Case Only Intervention Could Solve

A Step By Step Approach To A Case With No Alternative But Intervention
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Dr. Hiremath : <b/> One thing is clear from what you are seeing that patient needs a procedure. There is no medical treatment. So to me it is a low SYNTAX score and the steps could be quite definitive, so we go for PCI. In this particular case, just the location of the lesion is very critical. If patient has to come with stent thrombosis it would be a disaster. So I would probably choose ticagrelor or prasugrel to pre-treat this patient prior to the procedure and not use clopidogrel though the patient is not kind of any serious kind of situation. Between these two, I would choose heparin negative between keeping a balloon pump, no, because I feel the steps could be quite defined and if you are pretty quick on your result, you do not need to take a balloon pump (01:00). IVUS, yes of course; in this particular case we would do IVUS primarily to see if there is a calcification and if there is a need for ROTA cutting balloon etc., anyway the lesion when you prepare with a noncompliant balloon, more importantly it would give us a diameter of the left vein and to which level the stent needs to be stretched and also some insight about the ostium of the circumflex as well as the ramus. This would help you to sort of be ready for a two stage strategy, but as I see here there is no disease in the mouth of the ramus as well as the circumflex. So debulking probably not required in this particular case. You could stick to standard wire and balloon kind of an approach. Side branch wire, I would put wire in the ramus but not put wire in the circumflex (02:00). So the steps would be to sort of get a wire in LAD cutting balloon. This would be required because you would always find the ostia of the LAD to be hard. You may not do a rota ablator, but these ostia in a 61-year-old should be assumed, of course I would have helped you to make this kind of decision, but I would presume a cutting balloon would be quite important at this stage. The stent choice of course would be quite important at this stage. What we really need to know is the stent should have an ability to be stretched to 4.5 or 5.0. It should have good side branch access in case the side branch gets heavily pinched, we may need to go to the side branch, if you have to put a stent it should give us an adequate opening towards the side branch (03:00) and it should have a good radial strength. So choice probably would be between Resolute Integrity or Synergy. This is what I mean when the stent should be able to stretch itself in the left main, same stent would come back, so a different diameter in the LAD and a different diameter in the left main. The less red marks suggest that there is a good opposition to the stent. Then the side branch access, once you make a balloon ready would be of this nature. Synergy probably would be another good choice, the strut thickness on a bigger diameter Synergy is still 80. So I would rather trust it because it is going to be stretched to even 5.0 diameter (04:00). As you can see here, the 4.0 Synergy could be stretched all the way to 5.5 and even above that. So this could be a good choice. We have stent in place, at this stage we would look at the side branch especially the ramus. We would of course do a POT. So once you do the POT, access to the side branch becomes easy, so you have wire in place, you dilate the stent in the LAD and then you take a look at the side branch ramus. So, if there is a pinching you have an FFR to guide you as to whether it should be addressed (05:00). If this is significant, you have to take a decision whether you would stent or just do with balloon knowing that the length of the ramus I would probably be very inclined to put a second stent if the side branch is heavily narrowed. So a stent may be required and something like Alpine may be a good strategy because Alpine can sort of center itself when you are going through an opening here and an opening here and thus may be an easier stent to get into the distality and of course a final kiss and a final hug bring the same balloons back to expand the stent in the LAD. I think this would be my approach to handle this case.

One thing is clear from what you are seeing that patient needs a procedure. There is no medical treatment. So to me it is a low SYNTAX score and the steps could be quite definitive, so we go for PCI. In this particular case, just the location of the lesion is very critical. If patient has to come with stent thrombosis it would be a disaster. So I would probably choose ticagrelor or prasugrel to pre-treat this patient prior to the procedure and not use clopidogrel though the patient is not kind of any serious kind of situation. Between these two, I would choose heparin negative between keeping a balloon pump, no, because I feel the steps could be quite defined and if you are pretty quick on your result, you do not need to take a balloon pump (01:00). IVUS, yes of course; in this particular case we would do IVUS primarily to see if there is a calcification and if there is a need for ROTA cutting balloon etc., anyway the lesion when you prepare with a noncompliant balloon, more importantly it would give us a diameter of the left vein and to which level the stent needs to be stretched and also some insight about the ostium of the circumflex as well as the ramus. This would help you to sort of be ready for a two stage strategy, but as I see here there is no disease in the mouth of the ramus as well as the circumflex. So debulking probably not required in this particular case. You could stick to standard wire and balloon kind of an approach. Side branch wire, I would put wire in the ramus but not put wire in the circumflex (02:00). So the steps would be to sort of get a wire in LAD cutting balloon. This would be required because you would always find the ostia of the LAD to be hard. You may not do a rota ablator, but these ostia in a 61-year-old should be assumed, of course I would have helped you to make this kind of decision, but I would presume a cutting balloon would be quite important at this stage. The stent choice of course would be quite important at this stage. What we really need to know is the stent should have an ability to be stretched to 4.5 or 5.0. It should have good side branch access in case the side branch gets heavily pinched, we may need to go to the side branch, if you have to put a stent it should give us an adequate opening towards the side branch (03:00) and it should have a good radial strength. So choice probably would be between Resolute Integrity or Synergy. This is what I mean when the stent should be able to stretch itself in the left main, same stent would come back, so a different diameter in the LAD and a different diameter in the left main. The less red marks suggest that there is a good opposition to the stent. Then the side branch access, once you make a balloon ready would be of this nature. Synergy probably would be another good choice, the strut thickness on a bigger diameter Synergy is still 80. So I would rather trust it because it is going to be stretched to even 5.0 diameter (04:00). As you can see here, the 4.0 Synergy could be stretched all the way to 5.5 and even above that. So this could be a good choice. We have stent in place, at this stage we would look at the side branch especially the ramus. We would of course do a POT. So once you do the POT, access to the side branch becomes easy, so you have wire in place, you dilate the stent in the LAD and then you take a look at the side branch ramus. So, if there is a pinching you have an FFR to guide you as to whether it should be addressed (05:00). If this is significant, you have to take a decision whether you would stent or just do with balloon knowing that the length of the ramus I would probably be very inclined to put a second stent if the side branch is heavily narrowed. So a stent may be required and something like Alpine may be a good strategy because Alpine can sort of center itself when you are going through an opening here and an opening here and thus may be an easier stent to get into the distality and of course a final kiss and a final hug bring the same balloons back to expand the stent in the LAD. I think this would be my approach to handle this case.


Thank you.

Dr. MS Hiremath

President Elect, CSI, Director

Cardiac Cath Lab, Ruby Hall Clinic, Pune

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Tags:

  • Heart Attack
  • MI
  • ECG
  • Hypertension
  • Bypass
  • Surgery
  • Stent
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