Cath Conference July 30, 2008

Cath ConferenceCath ConferenceJuly 30, 2008July 30, 2008

Priya Pillutla, M.D.Priya Pillutla, M.D.

HistoryHistory

53 year old firefighter referred for 53 year old firefighter referred for cardiac catheterizationcardiac catheterization

Screening treadmill at outside hospitalScreening treadmill at outside hospital Early positive (CP, ECG changes)Early positive (CP, ECG changes)

Coronary CT at HUCLA with 50% LM, Coronary CT at HUCLA with 50% LM, LAD diseaseLAD disease

No rest pain, DOE or syncopeNo rest pain, DOE or syncope Otherwise no complaintsOtherwise no complaints

Priya Pillutla, M.D.

PMH – HTN, hyperlipidemiaPMH – HTN, hyperlipidemia Meds – benazepril, lipitorMeds – benazepril, lipitor NKDANKDA Social – No tobacco, +social alcohol, Social – No tobacco, +social alcohol,

no drugsno drugs


ExamExam

BP 128/80, HR 52, RR 14, sat 99% RABP 128/80, HR 52, RR 14, sat 99% RA Latino man in NADLatino man in NAD JVP 5 cmJVP 5 cm RRR nl s1/s2. No s3/s4. No murmursRRR nl s1/s2. No s3/s4. No murmurs Lungs clearLungs clear No edemaNo edema 2+ carotid/radial/brachial/femoral/DP 2+ carotid/radial/brachial/femoral/DP


Electrocardiogram Electrocardiogram (Treadmill)(Treadmill)


LHC/AngiographyLHC/Angiography


IVUSIVUS


SummarySummary

Treadmill – Early CP, ST depressionsTreadmill – Early CP, ST depressions Cardiac CT showed 40-50% LM disease, Cardiac CT showed 40-50% LM disease,

complex 50-60% mid-LAD stenosis complex 50-60% mid-LAD stenosis Left heart catheterizationLeft heart catheterization

40-50% LM with IVUS showing minimum 40-50% LM with IVUS showing minimum lumen area of 8.2 mm2lumen area of 8.2 mm2

40% ostial LAD lesion40% ostial LAD lesion 75-80% mid LAD lesion successfully stented75-80% mid LAD lesion successfully stented


Clinical CourseClinical Course

The patient was discharged on ASA The patient was discharged on ASA and plavixand plavix

He will follow up within 1 month for He will follow up within 1 month for nuclear stress testing to assess for nuclear stress testing to assess for ischemiaischemia


Assessment of Ambiguous Assessment of Ambiguous LM StenosisLM Stenosis

LM stenosis > 50% linked to poor LM stenosis > 50% linked to poor outcomesoutcomes Lesser stenosis also correlatedLesser stenosis also correlated

Limitations of angiography – 40-70% Limitations of angiography – 40-70% stenosisstenosis No reference segment proximally (short LM)No reference segment proximally (short LM) Remodeling (positive and negative)Remodeling (positive and negative) Geometry of the vesselGeometry of the vessel Intra- and inter-observer variability is highIntra- and inter-observer variability is high

CASS study – when one observer found > 50% LM CASS study – when one observer found > 50% LM stenosis, another said no stenosis 19% of the timestenosis, another said no stenosis 19% of the timeLeesar et al, CCI, 2007Leesar et al, CCI, 2007

Tobis et al, JACC, 2007Tobis et al, JACC, 2007))Priya Pillutla, M.D.

LM Ambiguity – Reasons?LM Ambiguity – Reasons?

Patients with LM disease almost Patients with LM disease almost always (87%) have CAD in other always (87%) have CAD in other vesselsvessels Thus noninvasive testing may show Thus noninvasive testing may show

balanced ischemiabalanced ischemia Are there other ways to assess Are there other ways to assess

burden of disease?burden of disease? IVUSIVUS FFR FFR


IVUS For Intermediate LM IVUS For Intermediate LM DiseaseDisease

Fassa et al, JACC, 2005Fassa et al, JACC, 2005 121 patients with normal or minimally 121 patients with normal or minimally

diseased LM had IVUS studiesdiseased LM had IVUS studies Lower range of normal was established Lower range of normal was established

(within 2 SD) for minimum lumen area as (within 2 SD) for minimum lumen area as 7.5 mm27.5 mm2**

Study period – 214 patientsStudy period – 214 patients If LM indeterminate then IVUS performedIf LM indeterminate then IVUS performed Revascularize if MLA < 7.5 mm2Revascularize if MLA < 7.5 mm2

* prior studies used * prior studies used 6 mm26 mm2


Distribution of MLADistribution of MLA


A: < 7.5mm2, revascularized B: < 7.5mm2, deferred

C: > 7.5 mm2, revascularized D: > 7.5 mm2, deferred

A vs D; A vs C, C vs D – p value not significant


ManagementManagement

Thoughts/suggestions?Thoughts/suggestions? Role of CT?Role of CT?


Cath Conference July 30, 2008

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