CCC Live Cases
Questions / Answers from March 9, 2010 Case

Questions / Answers

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What percentage of PCI use IVUS at your institution?
Total 10-11% of cases are done with IVUS; 60% diagnostic and 40% therapeutic. Most common utility of IVUS in our lab is to determine the significance of a borderline lesion. We follow the 4mm2 rule of lumen MLA; <4mm will undergo stent & if >4mm2 then defer PCI.
Do you use both the Boston Scientific and Volcano equipment?
YES; 4 BSC and 2 Volcano machines are in our cath lab.
How do you compare them?
iLAB of BSC is the preferred one for coronaries while Volcano is commonly used in conjunction with endovascular interventions. Virtual histology by Volcano is +for them.
Do you find the Virtual Histology useful?
Not really as we don't use it routinely. In rare cases, it is useful to evaluate the necrotic core. We are still analyzing and understanding the PROSPECT trial data for identifying high-risk lesions; vulnerable plaques.
Has the use of Pressure Wire for FFR made any difference in the use of IVUS?
We use either of the techniques in a given case; mostly IVUS only. Mostly (as supported by the published data), FFR is often >0.80 in borderline lesions (50-70% angiographically). Some of the contiguous multiple lesions, even moderate have surprised us by having FFR of <0.80.
Do you see the use of IVUS increasing for deploying DES?
In the US yes but not in our cath lab. Main reason for it is the strong emphasis on lesion preparation in our lab (Rota in 5-6% and Cutting balloon in 10-12% of complex calcified lesions).
Are you finding IVUS useful in managing in-stent restenosis (ISR)?
Yes. IVUS is great tool to evaluate the mechanism of ISR: stent under expansion vs. intimal hyperplasia. Therefore we frequently use IVUS in treating early (<6months) in-stent restenosis.
What newer improvements in IVUS do you find more exciting?
Virtual histology is one and chromo flow is other. New 60mHz catheter and forward looking IVUS for CTOs are the future developments keeping us excited about this technology. Also availability of OCT in future may dampen some of the IVUS enthusiasm.
How often are you using IVUS for LMCA interventions?
Not routinely at all. If the LMCA case is being done as live case, IVUS is commonly used. We do about 15-18 unprotected LMCA PCIs per month (which in my opinion is the largest volume compared to any other center in the US) and all are done with aggressive lesion preparation and angiographic guidance only. 'Stent Boost' system of Phillips X-ray, tremendously helps
further to confirm the stent expansion visually.
Do you see other technologies replacing IVUS?
YES. OCT availability will definitely impact the IVUS use negatively.
How are you using the SYNTAX score in your daily practice?
All non-CABG pts, are having SYNTAX score calculated after the angiogram and pts with SYNTAX score >32 (without contra-indication for CABG due to coexisting co-morbidities), are routinely being referred to CT surgery. Of course many times, these patients refuse CABG and then we end up in doing PCIs for them.
How is the volume of cardiac surgery holding up at your institution?
Still flat about 300-400 CABG per year of the total 1200-1300 CT surgery cases annually at Sinai. I believe that routine strategy of incorporating SYNTAX score in daily practice, will likely to impact positively in the CABG volume at MSH. That is the right thing to do as these pts really did better than Taxus DES PCI in the SYNTAX trial as well as in the SYNTAX registry.
How is your PCI volume and reimbursement in 2010?
YES PCI volume continue to rise over last five years with record 13% growth to 5800 total interventions (including 5078 PCIs) in 2009. We hope to duplicate the same # this year also; may even be better as we are already 70+YTD in interventional volume compared to 2009. As far as reimbursement is concerned, it has gone down by 12-15% overall because more pts are being done as Ambulatory as per strict new guidelines of In-hospital admissions post-PCI.
What are your favorite guide catheter shapes?
For RCA; IMA guide and for extra support AL 0.75
For LM; FL guide
For LAD; CL or Q curves
For LCx; VL or EBU guides
We commonly use MACH1 of BSC because of soft atraumatic tips.
And of guide wires?
Runthrough of Terumo and BMW of Abbott vascular are the workhorse wires. In tortuous/angulated cases, Fielder or Whisper wires of Abbott are the first line wires. For CTOs, we start with FilderXT or Cross it-100 and then move upto MiracleBro 3,6, 9
and ultimately Confianza pro 9 or 12.
Finally, stents?
Xience V makes upto 80-82% of DES volume with 10-12% Cypher and 6-8% Endeavor DES. DES is used in 82-84% of PCIs and BMS in remaining with largely Vision BMS of Abbott and some Liberte/Veriflex of BSC.
Why do you consider Xience V as the work horse stent in your lab?
Because of its deliverability, side branch preservations and plavix use for only one year. This all has resulted in very low incidence of definite DES thrombosis of <0.16% in our lab.
Would you like to see some improvements in it?
YES, especially to have less compliant balloon. Also improved radial strength for ostial and calcified lesions will be preferred.
Are your fellows getting experience in Radial procedures?
YES. About 10% of 13000 left heart or PCI cases are being done as radial. Hence they are getting good training and experience in radial catheterization also. One of our interventionalist does95% of his 300-350 cases radially.
Are you mandating that a part of their training?
YES. For the Interventional fellows only and not necessarily the regular Cardiology fellows. Clearly radial procedures requires extra skill set, learning curve and training but is a must for an interventionalist to be fully comfortable in this technique presently.
 

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