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Mt. Sinai Complex Coronary Case Highlights

Presented by ACC and the Mt. Sinai Medical Center.

82-year-old Male with Extensive 3-vessel Disease Who Declined CABG

This complex coronary case features an 82-year-old male with new-onset exertional dyspnea and negative stress myocardial perfusion imaging. However, coronary CTA revealed extensive calcific three-vessel coronary artery disease, leading to cardiac catheterization on January 10, 2014, which revealed extensive calcific three-vessel disease with normal left ventricular function and a high SYNTAX score of 36. Heart Team consultation led to a recommendation for CABG but was declined by the patient and family, partly due to a prior small cerebrovascular accident with no deficit. The patient was placed on optimal medical therapy but continued to be symptomatic. In this live case, the patient is planned for high- risk PCI of multiple calcific lesions of the right coronary artery as the first part of multivessel staged PCI. Various challenges are seen in this program which features the use of the Coronary Orbital Atherectomy System (CSI, St. Paul, MN).

2014 Cases

January 2014

Complex PCI in a Young Patient with Unstable Angina
This month’s master’s class in interventional cardiology features the case of a 52-year-old male with type 2 diabetes who presented on January 13, 2014 with new onset unstable angina (CCS class III-IV) and inferolateral T wave changes. Cardiac catheterization of this young patient revealed complex 2-vessel coronary artery disease with multiple lesions of the right coronary and left circumflex arteries, normal LV function, and a SYNTAX score of 23. The patient originally underwent implantation of three drug-eluting stents within the right coronary artery and he did well. This program presents his planned complex PCI of a calcified bifurcation and complex angulated lesions of the left circumflex coronary artery. Two specific issues are addressed in this program: the platelet responsiveness during PCI as well as contrast-induced nephropathy and the latest ways to prevent it.
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2013 Cases

December 2013

The Complex CAD Patient Declined for CABG Surgery
The December program featured a 69-year-old male who presented on November 4, 2013 with unstable angina. Cardiac catheterization revealed three-vessel plus left main (LM) CAD (95% calcified ulcerated proximal-mid right coronary artery [RCA]), an 80% calcified proximal left anterior descending (LAD) artery, a 60% blocked mid LAD, a 70% proximal left circumflex (LCx) artery, and a 60% distal LM with an LVEF 50% and a SYNTAX score of 45. Coronary artery bypass graft (CABG) surgery was recommended but declined after Heart Team discussion. The patient underwent Orbital atherectomy (similar to rotational atherectomy) and a DES x2 of proximal and mid RCA. Results were excellent and the patient did well. However, the patient continues to have CCS Class II angina and is now back for assessment of fractional flow reserve and optical coherence tomography-guided intervention of the LAD, LCx and LM using atherectomy and DES. Drs. Sharma, Kini and Mehta presented this complex coronary case LIVE from the cath lab at Mt. Sinai.
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October 2013

Shamin K Sharma, MD, recaps the October 2013 Complex Coronary Case
Samin K. Sharma, MD, re-caps a challenging case: a patient with severe left ventricular dysfunction and complex CAD. The procedure required use of a minimally invasive, catheter- based cardiac assist device (an Impella® LD Circulatory Support System; Abiomed, Inc.) to support atherectomy of the right coronary artery. The program provides step-by-step instruction in how to successfully use this approach in complex patients and avoid procedural complications.
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September 2013

Shamin K Sharma, MD, recaps the Complex Coronary Case Presented on 9/17/13
Shamin K Sharma, MD, recaps this month’s Complex Coronary Case, presented on September 17, 2013. A 56-year-old male with a 100% CTO in the mid LAD who previously (July 2013) underwent PCI of a proximal RCA chronic total occlusion treated with an Xience Xpedition (2.75/33mm) DES. The patient continued to have exertional fatigue (the presenting complaint back in July) despite his successful PCI and good medical therapy. He is back for recanalization of another chronic total occlusion but this time accessed via an antegrade approach. Treating CTOs is a new frontier for many interventionalists and this live case offers insight into the optimal care of these patients, including a discussion of the factors influencing the decision for antegrade recanalization.
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June 2013

62-year-old male presented with class I angina and positive stress echo on 6/4/2013.
A 73-year-old male with multiple CAD risk factors, CCS Class III angina and high risk MPI presented on 2/8/13. Cath revealed 3V CAD and LVEF 55% (SYNTAX Score 25). Patient has moderate to severe MR on echo. CABG and MVR was recommended but declined even after Heart Team consultation. Patient underwent PCI of proximal LAD and Ramus Intermedius using an everolimus eluting stent. Now staged for PCI of circumflex/OM1 bifurcation (Medina 1,1,1).
Watch the Highlights Video Video | Archived Case With CME PDF

March 2013

A 73-year-old male with multiple CAD risk factors, CCS Class III angina and high risk MPI presented on 2/8/13.
A 73-year-old male with multiple CAD risk factors, CCS Class III angina and high risk MPI presented on 2/8/13. Cath revealed 3V CAD and LVEF 55% (SYNTAX Score 25). Patient has moderate to severe MR on echo. CABG and MVR was recommended but declined even after Heart Team consultation. Patient underwent PCI of proximal LAD and Ramus Intermedius using an everolimus eluting stent. Now staged for PCI of circumflex/OM1 bifurcation (Medina 1,1,1).
Watch the Highlights Video Video | Archived Case With CME PDF

February 2013

60-year-old male with multiple CAD risk factors, CCS Class II angina, presented on 12/21/12 with high risk stress echo for inferior and lateral ischemia.
60‐year‐old male with multiple CAD risk factors, CCS Class II angina, presented on 12/21/12 with high risk stress echocardiogram for inferior and lateral ischemia. Cath revealed 2V CAD (SYNTAX score 20), normal LV function. Patient had successful PCI (DES) of LCx-high lateral. Now scheduled for complex PCI of RCA CTO via antegrade or retrograde approach.
Watch the Highlights Video Video | Archived Case With CME PDF | Download the Presentation PDF

January 2013

68-year-old male with multiple CAD risk factors, CCS Class III angina and low risk MPI presented on 12/28/12.
68-year-old male with multiple CAD risk factors, CCS Class III angina and low risk MPI presented on 12/28/12. Cath revealed 3 vessel and left main disease and hyperkinetic LV function (SYNTAX score 33). Patient had a heart team consultation and CABG was strongly recommended but declined by the patient. The patient is now scheduled for complex high-risk PCI of unprotected left main bifurcation.
Watch the Highlights Video Video | Archived Case With CME PDF

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