Chapters Transcript Video Coronary Physiology Case #2 This is an 82 year old woman. She came in with an N sty. She has a rather routine past medical history for those that we see in the hospital with this presentation including chronic kidney disease, which is a real issue for us in the Cath lab and often leads to people uh not receiving what we would otherwise considered standard of care therapies for their coronary disease due to the concern for contrast induced nephropathy. Um So she went for a diagnostic catheterization which revealed this L ad lesion. I won't show the rest of the NGO because it wasn't particularly interesting and had a stage intervention due to her kidney disease. In this case, we took one setup shot and the rest we were able to do with intravascular imaging. So this is our guide shot probably four CCS five CCS of contrast. And we were able to then uh superimpose our IVIS imaging over this utilizing a co registration. At this point. We understand the lesion dimensions. We understand the lesion composition. We see that we can probably get by with standard balloon angioplasty as lesion preparation without ancillary calcium modification. And we pretty much have our procedure planned out from here. Um Further utilizing the software to define stent length very precisely before we endeavor upon placing it, we skeletonized that uh diagonal branch. So we had a good concept of where our distal landing zone would be without providing additional contrast. This is our stent placement. We optimized it. We used I vs to verify those previously defined ultimate criteria and then took one outshot with a good result. And she did well clinically with a procedure that utilized less than 10 CCS A die with good results. So uh I think that exemplifies where you know, potentially upfront use of imaging might save us from uh you know, the catastrophe of potentially stent under expansion and other issues. But there is one other thing that's not identified angiographically pivotable in optimizing uh outcomes in these patients. That's physiology. So we have a better understanding of the an atomic construct of the vessel and we use multiple imaging modalities, but we're really targeting functionally significant lesions and trying to defer interventions on nonfunctional significant lesions. As we know those two things are pivotal in improving outcomes among patients undergoing intervention. And that was seen in the Syntex two trial where there was mandatory um uh hybrid functional assessment of coronary lesions in the trial using both Ifr and FFR targeting only functional significant lesions deferring lesions that were not functionally significant also with liberal use of intravascular imaging. And compared to prior uh Syntex one trial, which was otherwise similar in terms of patient population outcomes were considerably improved, uh specifically, with respect to mace out to two years. And so that leads us to our third case, 79 year old woman, she had refractory Angina. She had the typical cardiovascular risk factors and she had a Coronary CT A that showed that she had severe L AD disease. So she came to the Cath lab and we were able to better define that this is our uh angio. And so she has a proximal uh aneurysm and certainly in, in large uh aneurysms, particularly in young people, there may be some benefit to occlu those. But in this case, in our 79 year old woman who had refractory symptoms of angina, I don't think that that was her clinical problem and that, you know, poses an issue, you know, when it comes to protecting that diagonal branch. Um but she also has discrete mid vessel disease. And so the question is really where best to target our treatment and how, you know, to approach this procedurally to help her symptoms without incurring any additional risk factors than necessary as it relates to uh downstream uh complications. And we were able to use physiology also um utilizing co registration in this case to define where the functional against in this vessel was. And it turns out that that area immediately surrounding the aneurysm was probably not causing her uh clinical symptoms So it wasn't her clinical issue, but you did have a significant gradient across the midsegment those yellow dots reflect the degree of hemodynamic significance with an overall ifr distally of 0.7 which is highly functionally significant. So we again uh per our routine use intravascular imaging to further refine our approach, we were able to place a stent that uh was well opposed, expanded and appropriately landed without bringing into involvement that proximal aneurysm. And she did quite well clinically uh following this has not needed recurrent uh angiography or uh further functional imaging post ifr was 0.97. Um So we know that we achieved a good physiologic result. And so finally, um this case is a little more complicated and I think we utilized uh both IVIS and Ffrifr in this case to really refine our approach and simplify what was uh a complex situation. It's a 55 year old gentleman, he had refractory angina and heart failure. Um He actually related to us that he had chest pain for the better part of a year uh with exertion prior to his presentation. But what really caused him to seek medical attention fairly stoic high was um profound edema and shortness of breath. His ef uh on an echo when he came in was 20%. He was medically optimized for his heart failure before he was taken to the Cath lab. And once he was euvolemic, he uh underwent both the right and left heart cath, the angiography is shown here. So he has a totally occluded L ad he also has some disease in his circumflex. Um And he's got an RC A that's quite large and provides uh considerable contralateral collaterals to his led. We had a lot of deliberation with our surgery colleagues here and, and what we call a heart team approach um to treatment of this patient because it's a pretty complex situation. His clinical uh I should say his anatomy was probably best approached surgically, but he was uh intermittently inotrope dependent throughout his hospital course. And it was felt that he was particularly high risk. He was also quite opposed to surgery. So, um after our heart team conversation, it was felt that the balance of risks and benefits as well as consideration of patient preference, all likely favored percutaneous revacation. The ifr of that circumflex is importantly, not functionally significant. So despite having disease there, it likely would not provide incremental clinical benefit to revascularize that circumflex and in the bottom left hand corner is an ibis image of the ostium of the circumflex. That's, you know, quite important for me in procedural planning. When I'm thinking about how I'm going to approach, what involves a left main bifurcation and potentially say bifurcation, stenting, which we know leads to a higher tendency for instant re stenosis. So we did utilize an impala, which is not the focus of this talk, but it was certainly pivotal in this case, as it relates to his hemodynamic uh tenuous status and his reduced ejection fraction while we're fixing this. Um And we can see the uh rights sided collaterals of better defining with this dual injection angio, the proximal CTO, we put a wire in the circumflex for protection and then we went to work antegrade and thankfully got approach uh got across without having to utilize a retrograde approach here. Um We were able to place two overlapping stents extending from the left main into the led with uh you know, considerably improved flow certainly into the anterior territory, but importantly, did not have to bring into play bifurcation stenting. We recently saw him back in the office. This is, you know, eight months or so, post intervention is ef is now 45% and he's uh now routinely following us on the yearly intervals. Published November 14, 2024 Created by Related Presenters Paul Lavigne, M.D. Sentara Cardiology Specialists View full profile
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