cath conference july 30, 2008 priya pillutla, m.d
TRANSCRIPT
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
Priya Pillutla, M.D.
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
Priya Pillutla, M.D.
Electrocardiogram Electrocardiogram (Treadmill)(Treadmill)
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
Priya Pillutla, M.D.
LHC/AngiographyLHC/Angiography
Priya Pillutla, M.D.
IVUSIVUS
Priya Pillutla, M.D.
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
Priya Pillutla, M.D.
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
Priya Pillutla, M.D.
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
Priya Pillutla, M.D.
Priya Pillutla, M.D.
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
Priya Pillutla, M.D.
Distribution of MLADistribution of MLA
Priya Pillutla, M.D.
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.
ManagementManagement
Thoughts/suggestions?Thoughts/suggestions? Role of CT?Role of CT?
Priya Pillutla, M.D.