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Cath Conference July 30, 2008

Cath Conference July 30, 2008. Priya Pillutla, M.D. History. 53 year old firefighter referred for cardiac catheterization Screening treadmill at outside hospital Early positive (CP, ECG changes) Coronary CT at HUCLA with 50% LM, LAD disease No rest pain, DOE or syncope

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Cath Conference July 30, 2008

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  1. Cath ConferenceJuly 30, 2008 Priya Pillutla, M.D.

  2. History • 53 year old firefighter referred for cardiac catheterization • Screening treadmill at outside hospital • Early positive (CP, ECG changes) • Coronary CT at HUCLA with 50% LM, LAD disease • No rest pain, DOE or syncope • Otherwise no complaints Priya Pillutla, M.D.

  3. PMH – HTN, hyperlipidemia • Meds – benazepril, lipitor • NKDA • Social – No tobacco, +social alcohol, no drugs Priya Pillutla, M.D.

  4. Exam • BP 128/80, HR 52, RR 14, sat 99% RA • Latino man in NAD • JVP 5 cm • RRR nl s1/s2. No s3/s4. No murmurs • Lungs clear • No edema • 2+ carotid/radial/brachial/femoral/DP Priya Pillutla, M.D.

  5. Electrocardiogram (Treadmill) Priya Pillutla, M.D.

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  9. LHC/Angiography Priya Pillutla, M.D.

  10. IVUS Priya Pillutla, M.D.

  11. Summary • Treadmill – Early CP, ST depressions • Cardiac CT showed 40-50% LM disease, complex 50-60% mid-LAD stenosis • Left heart catheterization • 40-50% LM with IVUS showing minimum lumen area of 8.2 mm2 • 40% ostial LAD lesion • 75-80% mid LAD lesion successfully stented Priya Pillutla, M.D.

  12. Clinical Course • The patient was discharged on ASA and plavix • He will follow up within 1 month for nuclear stress testing to assess for ischemia Priya Pillutla, M.D.

  13. Assessment of Ambiguous LM Stenosis • LM stenosis > 50% linked to poor outcomes • Lesser stenosis also correlated • Limitations of angiography – 40-70% stenosis • No reference segment proximally (short LM) • Remodeling (positive and negative) • Geometry of the vessel • Intra- and inter-observer variability is high • CASS study – when one observer found > 50% LM stenosis, another said no stenosis 19% of the time Leesar et al, CCI, 2007 Tobis et al, JACC, 2007) Priya Pillutla, M.D.

  14. LM Ambiguity – Reasons? • Patients with LM disease almost always (87%) have CAD in other vessels • Thus noninvasive testing may show balanced ischemia • Are there other ways to assess burden of disease? • IVUS • FFR Priya Pillutla, M.D.

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  16. IVUS For Intermediate LM Disease • Fassa et al, JACC, 2005 • 121 patients with normal or minimally diseased LM had IVUS studies • Lower range of normal was established (within 2 SD) for minimum lumen area as 7.5 mm2* • Study period – 214 patients • If LM indeterminate then IVUS performed • Revascularize if MLA < 7.5 mm2 Priya Pillutla, M.D. * prior studies used 6 mm2

  17. Distribution of MLA Priya Pillutla, M.D.

  18. 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 Priya Pillutla, M.D.

  19. Management • Thoughts/suggestions? • Role of CT? Priya Pillutla, M.D.

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