Is Stenting or Coronary Artery By-pass Grafting the Better Treatment for This Patient?

Transcription

1 Is Stenting or Coronary Artery By-pass Grafting the Better Treatment for This Patient? --- NIRS-IVUS TVC Imaging Adds Additional Information for the Heart Team Dr. Luis Tami Memorial Regional Hospital Hollywood, FL

2 Patient History 64 year old female with unstable angina. Severe COPD requiring home oxygen for 2 years, obesity, hypertension, peripheral vascular disease, dyslipidemia and diabetes.

3 Angiographic Findings Total occlusion of the RCA with L to L collaterals filling PDA. An anomalous LCX is occluded and fills with L to L collaterals. Moderate stenosis by angiography is present in the left main. Ventriculogram shows inferior hypokinesis with EF 25%.

4 IVUS Imaging Results The L Main lesion observed on angiogram is shown by IVUS to cause significant narrowing with a minimal lumen area of 3.9 mm 2. Hence, this unstable angina patient has critical L main stenosis, plus an occluded RCA and LCX. The stenotic L main provides the almost all flow to the heart. Revascularization with CABG or stenting is required.

5 What is the Best Mode of Revascularization for this Patient? For CABG: Very high Syntax score, indicating high risk PCI. Good distal vessels for surgical bypass. Prevention of future coronary events by distal bypass insertion. Diabetic The risk of L Main PCI is increased by occluded RCA. Stenting L main only will not provide complete revascularization. For PCI: A L main stent could provide immediate relief for unstable angina and protect essential coronary flow. Very high STS score due to COPD requiring home oxygen, PVD, obesity, indicating high surgical risk. Recovery from PCI more rapid than recovery from CABG. Patient, family and cardiac surgeons prefer the stenting option.

6 The Potential Benefit of Determining the Amount of Coronary Lipid in a Patient with Extensive Disease Visible on Angiography Disparity Between Angiographic Coronary Lesion Complexity and Lipid Core Plaques Assessed by Near-Infrared Spectroscopy Zynda,Thompson, Khiet, Hoang, Seto, Glovaci, Wong, Patel, and Kern,CCI, 2013 In 78 patients, Lipid Core Burden Index was only weakly correlated with angiographic Syntax score. In the present case could there be extensive lipid that might complicate stenting and elevate risk beyond that indicated by the Syntax score which is based on angiographic findings?

7 NIRS Imaging Provides Additional Information The stenotic lesion in the L main also contains a large, circumferential LCP which extends into the ostium of the LAD. MaxLCBI4mm: 705 MLA: 3.9mm2 PB: 65% Left Main

8 The L Main Lipid Also Extends into the LAD, thus Involving the Bifurcation with the LCX LCX LAD

9 Extensive Lipid-rich Plaque (LRP) has Been Shown to Increased Short and Long-term Complications of Stenting While the risk/benefit ratio for stenting flow-limiting lesions is generally positive, stenting a site with increased LRP is associated with -- No-reflow and peri-stenting MI Goldstein et al., Circ Cardiovascular Interventions 2011 Brilakis et al, CCI, 2012 Stone et al, CANARY, TCT 2014 Early stent thrombosis. Sakhuja et al, Circulation 2010 Plaque shift into side branches. Husaini et al, CCI B-070, 2014 Stent failure post PCI. Dohi et al, JACC TCT-583, 2013

10 Stent Failure Post Placement Over a Stenotic Lesion with Elevated Max LCBI 4mm Similar to that of the Present Case Pre Stenting Index PCI Post Stenting In-stent Restenosis after 8 months Stent Segment DES 3.0x15mm Pre PCI NIRS findings MaxLCBI4mm in stent segment: 936 Dohi et al, JACC TCT-583, 2013

11 Excellent Outcome in a Prior Case in Which a Stent was Placed for a Stenotic Lesion with Minimal LRP Pre Stenting Post Stenting Stent segment Xience 2.5x23mm Xience 2.5x23mm Xience 2.5x15mm Pre PCI NIRS findings MaxLCBI4mm in stent segment: 157 Dohi et al, JACC TCT-583, 2013

12 Increased maxlcbi 4mm in the Stented Segment Grouped by Occurrence of Stent Failure 478 stented patients with a DES - mean FU = 392 days. 13 cases of stent failure MaxLCBI 4mm Current Case = 705 P=0.043 The Max LCBI 4mm at baseline was significantly greater in those with stent failure. DES failure was not seen if Max LCBI <100. MaxLCBI 4mm The current case has extensive LRP at the potential stenting site. 0 Stent Failure Non-Stent Failure N = 13 N = 30 Dohi et al, JACC TCT-583, 2013

13 In the Current Case the Max 4mm LCBI in the Target Lesion in the L Main was 705

14 Clinical Plan, and Outcome The NIRS finding of lipid in the L main was an additional piece of data in favor of CABG. A NIRS finding that the L main did not contain lipid would have been data in favor of PCI. Assessing the balance of findings for PCI or CABG, the interventional cardiologist recommended CABG. The recommendation for CABG and the supporting evidence, including the chemogram, were presented to the patient, family and surgeons. CABG was selected by consensus. A LIMA was placed to the LAD, SV to PDA and SV to the anomalous LCX. The ejection fraction increased from 25 to 35% and the patient is doing well 1 month post surgery. NIRS IVUS TVC imaging provided useful information for the heart team in deciding between PCI and CABG.