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APPROACH TO LEFT MAIN CORONARY ARTERY DISEASE.pptx
- 1. APPROACH TO LEFT MAIN CORONARY ARTERY DISEASE Dr. Chaitanya Chittimuri PCI VS CABG
- 2. • Medically treated LM D/s – 75 mortality at 15 years • CABG – recommended in all significant LM D/s, SIHD Revascularisation LM D/s : >50% Luminal Diameter Intermediate 50-69% Severe 70-90% Critical >90% LM D/s location Ostial 23% Mid Shaft 15% Distal 61% Isolated LM D/s 4-6 % Urgent / Emergent 17-59%
- 3. DECISION MAKING • CLINICAL FACTORS • PROCEDURAL CONSIDERATIONS • OPERATOR / INSTITUTION ISSUES • COMPARATIVE TRIALS • CURRENT GUIDELINE • REAL WORLD DATA • PRACTICAL APPROACH Firstly, The Factors important to the patient : • symptom relief • recovery time • freedom from complications post-procedure • longevity Objectively determining Patient outcomes • Clinical Risk Score (STS ,the EuroSCORE II) • Integrated anatomical and clinical scores -the SYNTAX ,SYNTAX II 2020
- 6. TECHNICAL CONSIDERATIONS PCI IN LM DISEASE • Anatomy of LM • Intravascular imaging lesion severity technical PCI approach proper stent sizing stent apposition • Functional testing hemodynamic significance side branch compromise CABG IN LM DISEASE • Nature of isolated LM lesions • Distal epicardial vessels (minimum 1.5 mm) • Calcified walls • Intramyocardial course • Choice of Graft - LM bifurcation • Unstable during induction of anesthesia • Cardioplegia Delivery • Porcelain aorta or aorta with atheroma • Reoperative surgery must be factored • Risk of deep-sternal wound infection
- 12. Marc Ruel. Circulation. Why NOBLE and EXCEL Are Consistent With Each Other and With Previous Trials, Volume: 135, Issue: 9, Pages: 822-824, DOI: (10.1161/CIRCULATIONAHA.116.027159)
- 20. Unmet Issues on Left Main Revascularization MI definition Complete (CR) or incomplete revascularization (IR) Role of IVUS or FFR All-cause mortality or cardiac mortality Long-term follow-up data beyond 5or10 y Optimal antithrombotic strategy and DAPT duration Role of SYNTAX score
- 23. Thank You
Editor's Notes
- Older patients are underrepresented, Fraility not considered.
- IVUS for significance of stenosis. 6sq mm vs 4.5sq mm