Thoughtful Insights at TCT: Dealing With Complex CAD Cases

 Washington, DC—How the presence of cardiogenic shock or diabetes influences decision making spurred conversation at the “Complex Coronary Artery Disease” session on the final day of TCT 2014, as did the roles of adjunctive technologies in treating patients.

Three case presentations were made, each followed by a “thoughtful insights” response and discussion. Presentations addressed the management of multivessel disease in a patient with diabetes, treatment of STEMI in a patient with cardiogenic shock, and where fractional flow reserve (FFR) and IVUS fit into the treatment of patients with complex disease.

Unprotected Left Main Coronary Disease

As part of one presentation, two cases highlighted the potential uses of FFR and IVUS, either individually or in combination, for guiding the management of patients with unprotected left main disease.

Starting off his “thoughtful insights” presentation, Patrick W. Serruys, MD, PhD, of Erasmus Medical Center (Rotterdam, the Netherlands) (London, England), showed data demonstrating that angiography can lead to both underestimation and overestimation of the significance of left main lesions. FFR guidance in the decision to treat unprotected left main disease, on the other hand, is associated with a survival benefit. “Clearly the message here is that when you have a good FFR you can defer the procedure,” he said.

But getting a reliable FFR measurement might be challenging, Dr. Serruys added, pointing to a study showing that the process could be complicated when the degree of stenosis increases along the length of a vessel such that there is an increase in coronary flow reserve into a branch. That could result in false-positive and false-negative FFR values.

“FFR has gotten a little bit more complicated than just passing a pressure wire, giving adenosine, and seeing what the measurement is across a lesion,” TCT Course Director Gregg W. Stone, MD, of Columbia University Medical Center (New York, NY), noted.

Dr. Stone then asked Gary S. Mintz, MD, of the Cardiovascular Research Foundation (New York, NY), when he would choose to use IVUS instead of FFR for left main disease.

Preferences vary by operator, Dr. Mintz said. “The advantage of IVUS is that when you go ahead to treat [left main disease] you then can optimize outcomes and/or optimize stent implantation,” he explained, pointing to prior studies showing the IVUS-guided left main stenting is associated with lower mortality compared with angiography-guided stenting.

“Listening to these sophisticated analyses of both physiology and anatomy, you get confused,” commented Eberhard Grube, MD, PhD, of University Hospital Bonn (Bonn, Germany). “If you have to read a physiology book before you can treat diffuse LAD disease, it gets very complicated.”

“I think we should be a little bit more practical,” Dr. Grube said. “Go with IVUS. Look at the diameters and then go from distal to proximal, and go ahead and do what we have to do. And then if there’s any doubt left, I think we can use FFR. But I think it’s confusing information.”

Diabetes and Multivessel Coronary Disease

In a “thoughtful insights” presentation following a case involving a 77-year-old man with insulin-treated type 1 diabetes who underwent multivessel PCI that included the RCA and the diagonal branch of the LAD, Steven P. Marso, MD, of the University of Texas Southwestern Medical Center (Dallas, TX), reviewed findings from the large trials comparing CABG with PCI in patients with multivessel disease. He pointed out that most of them—including the FREEDOM, BARI, and SYNTAX trials—showed a survival advantage for diabetic patients treated with CABG through 5 to 10 years of follow-up.

Other factors come into play, however, including Syntax score and insulin use, he said. In both FREEDOM and SYNTAX, the benefit for CABG appeared to be greater in patients with higher Syntax scores. But the trials provided discordant results regarding the influence of insulin: in SYNTAX, the risk of MACE was higher with stenting only among patients treated with insulin, whereas in FREEDOM, the advantage for CABG was not modified by insulin use.

“Trial data suggest that CABG is superior to PCI in patients with multivessel disease,” Dr. Marso said. “When considering treatment options for individuals, though, I think we need to acknowledge that the treatment effect [of CABG] is greater for people with diabetes and Syntax scores greater than 22 and for insulin-treated patients in SYNTAX but not FREEDOM.”

Referring to this specific case, William W. O’Neill, MD, of Henry Ford Hospital (Detroit, MI), said surgery would have been a better option, noting that there was disease distal to the stent placed in the LAD. “We’re doing spot management of a systemic disease [with diabetics], and I think that’s why surgery wins in these patients, because PCI patients have more infarctions in the future from areas that weren’t covered by the stents,” he said.

But in this case the graft would have had to bridge the diagonal branch, which cannot be done in many centers, TCT Course Director Martin B. Leon, MD, of Columbia University Medical Center (New York, NY), pointed out.

“I think you do have to look at each patient and look at the anatomy to try to make those decisions,” Dr. Leon said. “Surgery would have been a very good option, but I think that there are some limitations of surgery also with this kind of multifocal diffuse disease.”

STEMI With Hemodynamic Compromise

In his “thoughtful insights” presentation, Steffen Desch, MD, of University of Schleswig-Holstein, Campus Lübeck (Lübeck, Germany), raised 2 issues related to a case involving a 46-year-old man with STEMI and cardiogenic shock who ultimately recovered after placement of an intraaortic balloon pump (IABP), primary PCI of the RCA, and extracorporeal membrane oxygenation (ECMO).

First, Dr. Desch said, IABPs probably should not be used anymore based on the results of the IABP-SHOCK II trial, which support the class III (level of evidence A) recommendation against routine use in patients with cardiogenic shock in the most recent revascularization guidelines from the European Society of Cardiology.

Robert C. Welsh, MD, of Mazankowski Alberta Heart Institute (Edmonton, Canada), acknowledged that IABPs should not be used routinely but said that in certain cases there are no other options. In this case, the patient was not responding and the operator had to try something to get through the procedure, he said, noting that many centers do not have the ability initiate ECMO rapidly in the cath lab. “You’re stuck in this case,” he said. “So I think it’s something we have to do to get the job done.”

The second issue raised by Dr. Desch was what to do when a patient has multivessel disease and cardiogenic shock. Although PRAMI and CvLPRIT have provided support for complete revascularization of all significant lesions in patients with multivessel disease, the situation might be different in shock patients. Though likely biased, most published registries have suggested that single-vessel PCI might be preferred, Dr. Desch said. He added that the ongoing CULPRIT-SHOCK trial will aim to settle the question by randomizing about 700 patients with acute MI-related cardiogenic shock to immediate multivessel PCI or PCI of the culprit vessel only.

Dr. Stone said, “In shock, our traditional teaching had always been that… once you open up and get things restored in the infarct region, if the patient continued to have severe hemodynamic compromise and there was hypokinesis in the noninfarct zone, then you could consider doing [multivessel PCI].”

• Dr. Marso reports receiving grants/research support from AstraZeneca, Bristol-Myers Squibb, Novo Nordisk, Terumo, and The Medicines Company and consulting fees/honoraria from Novo Nordisk and St. Jude Medical.
• Dr. O’Neill reports receiving consultant fees/honoraria/speaker’s bureau payments from Edwards Lifesciences and Medtronic and having equity in Aegis and Neovasc.
• Dr. Welsh reports receiving grant support/research contracts from AstraZeneca, Bayer AG, and Edwards Lifesciences and consultant fees/ honoraria/speaker’s bureau payments from Abbott Vascular, AstraZeneca, Edwards Lifesciences, Medtronic, and Sanofi-Aventis.
• Dr. Stone reports receiving consultant fees/honoraria/speaker’s bureau fees from Reva and TherOx and having equity in Artasis, Biostar Funds, Caliber, Guided Delivery Systems, MedFocus Funds, Micardia, and VNT.
• Dr. Mintz reports receiving grant support/research contracts from Boston Scientific, InfraReDx, and Volcano and consultant fees/honoraria/speaker’s bureau payments from ACIST, Boston Scientific, and Volcano.
• Drs. Grube and Leon report relationships with multiple device companies.
• Drs. Desch and Serruys report no relevant conflicts of interest.

Related Stories:

• FREEDOM: CABG Superior to PCI in Diabetic Patients with Multivessel Disease
• Usefulness of IABP Questioned in MI Patients with Cardiogenic Shock
• SCAI Paper Outlines ‘Best Practices’ for FFR, IVUS, OCT