Heartfelt with Dr Melissa Walton-Shirley

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MULTI-VESSEL PCI CORONARY--- GRAND SYNTAX STYLE-TRUE GRIT AWARD

Oct 15, 2008 14:32 EDT


site:  St. Paul Hospital Vancouver

Case:  48 y.o. male prior smoker, stable angina, NYH II, +stress for ischemia anteroapical position, EF 48%, with exercise decreases to 41%.  Coronary anatomy:  40% left main, 100% LAD, Severe diffuse RCA with 100% occlusion.  Collaterals from Cx  and LAD to the  RCA. 

In some views, I thought  the left main seemed more than 40%.  Dr. Stone also verbalized that observation/concern.    Another panelist said "This is the 1st time I've moderated a case in which I'm saying 'this is a surgical case'.  For added drama and further insight, the cardiologist had asked the surgeon to scrub in who added that if he could have done this case, he would have been a good RIMA/LIMA candidate. He's obviously a good sport but standing by on a case like this  has to be as frustrating to a surgeon as it is to my husband  when I  turn on the TV but hide the channel changer. 

Technique:  Double injection with R and L judkins catheters -2 hydrophilic wires in the RVside branch and RCA, PTCA then IVUS--3.5x38mm DES post dilated with 4.0 balloon with absolutely BEAUTIFUL RCA TIMI wonderful flow .

Next, 2 wires in the ramus and cx, the CTO wire to theLAD.  Much difficulty trying to get across.  We leave the case and go to another case.  When we come back, the wire is obviously Sub-intimal.  Patient is fine without symptoms. Surgeon is hovering probably thinking I would be done by now and having supper if I could have done this case . 

Discussion: Stone:  " Could we go retrograde from the RCA and kiss the wires?" Another panelist commented:  " You know, an arterial graft might not have matured on this small LAD, maybe this wasn't such a bad case after all for PCI:. The operator:  " Let's IVUS it to see where we are.  Did we go subintimal at the proximal or mid LAD?"

 Dr. STone then added "in the context of SYNTAX, you know that we CAN do these lesions but in some cases there is still a bridge too far". Then a question for  Dr. Abel (seems to be a very patient and very nice surgeon, unless of course he too was just premedicated for this case)," will you do the RCA since it's open if you operate this patient? "Reply:  maybe I'll do a RIMA too.  Dr. Stone: "has he been loaded with clopedigrel?" reply:" No ,just maintained on it and asa, I won't load until the LAD wire is distal."  Dr. STone:  "How did you decide to do the RCA first?"  Reply: "It's just a matter of taste". 

I can't tell you how this came out. Time got away from us.   If anyone knows, please feel free to add a comment.  I happen to agree with Dr. Stone on this one, but I admitt that the RCA result was such a beautiful thing to behold and the operator was so confident, I would not be suprised if the patient isn't being discharged tomorrow.  If that's the case, this operator gets the TRUE GRIT award for this afternoon.





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Your comments
MULTI-VESSEL PCI CORONARY--- GRAND SYNTAX STYLE-TRUE GRIT AWARD
# 1 of 3
October 15, 2008 07:26 (EDT)
Marco

Hello, the case you describe, if attempted by PCI should start from LAD. In the case of failure a LIMA graft to LAD  is still a possible solution. Now with a long stent on a large right coronary, suboptimal result on LAD and DAPT is a more difficult situation to manage by surgery.

Bye

# 2 of 3
October 16, 2008 06:34 (EDT)
melissa

I've been going over this case in my head and I'm dying to know how it came out.  I'm going to be talking to Gregg tomorrow as sort of a meeting wrap up and I'll ask him how this case went down.  There is still something about that left main, depressed LV function and multivessel disease that takes me to the OR with this patient, though I understand the comorbidities were the concerning issue.  WE'll see. Thanks for your post.

Melissa
# 3 of 3
November 14, 2008 07:27 (EST)
Melissa

I believe this gentleman wound up in the OR. 

Melissa

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About Dr Melissa Walton-Shirley
Dr Walton-Shirley performs invasive cardiology, nuclear cardiology, and stress echocardiography in a private practice in Glasgow, KY.

Her chief medical interests are CHF/hypertrophic obstructive cardiomyopathy and the promotion of primary PCI for acute MI. Recently she played a significant role in helping to launch an ambitious pilot study of primary PCI in Kentucky, the Kentucky Primary Angioplasty Pilot Project. She has also participated in the TIMI 19, Duke-HF, NRMI, and CRUSADE trials and is proud to have been an advocate of the first smoke-free initiative in Kentucky (2011). She champions a smoke-free America.

Dr Walton-Shirley received her undergraduate degree at the University of Kentucky and went to medical school and did her residency and fellowship at the University of Louisville. She is married with two daughters. Her interests include singing, writing poetry and songs, fitness, and, of course, theheart.org.