Conquering left main disease is considered as crowning glory for the Interventional cardiologists. For over three decades , CABG has remained the undisputed modality which is being challenged today. Fortunately, the Incidence of true isolated left main disease is low .(If Medina bifurcation subset is excluded)
With growing expertise , advanced hardware and Imaging ( like a 360 degree OCT fly through view ) one can virtually sit inside the left main and complete a PCI .
Still , coronary care is much . . . much . . . more than a technology in transit !
Most importantly, these complex PCIs require rigorous maintenance protocol with meticulous platelet knockout drugs , patient compliance and the genetic fate of drug efficacy . (Clopidogrel has since entered the final laps of inefficiency while Ticagrelor has some more time I guess !)
What is the current thinking about unprotected left main PCI ? Let us know it from real life experts !
For those answered , yes to the above question please leave this page , as the following question might trouble you much !
While competent surgeons are waiting to tackle left main by surgical means ,there are many centers which are Inclined towards PCI though we lack long-term outcome (At least 10 years like CABG )
Why do you think this is happening ? Are you ready for another crooked poll ?!
What exactly is left main disease ?
Some of us also suffer from a knowledge gap and tend to think Bifurcation lesions and left main disease are two distinct entities .The fact of the matter is , significant subset of bifurcation lesions are Indeed either left main equivalents or true left mains ( Medina 1,1,1 would constitute > 50 % all bifurc lesions ) If you include Invisible left main lesions in Medina ( 0,1,1 or 0,0,1 ) detected by IVUS/OCT it might reach easily cross 90% (Scientific guess !) Does that mean we have to think CABG even for all complex bifurcation lesions ? and reserve left main disease for isolated discrete mid shaft or ostial left main ?
Final message
My observation (Sincere to my limited conscience !) at least in this part of the world is : Left main Interventions are “perceived as pride” and its more related to “show of expertise” and is little to do with patient outcome.Unfortunately , cardiologists should not be blamed for it in isolation as the studies they follow are conflicted.
Forget SYNTAX/PRECOMBAT trials, the two famous studies EXCEL (Favor PCI) and NOBLE were published in 2016 made our life tough .One suggested PCI is acceptable /on par with CABG, while the other one put CABG superior , ensuring clarity replaced with confusion ! When we have a dispute , logic would suggest we should fall back on the status quo ie “CABG is superior” unless proved convincingly. Many sections of cardiology society failed to appreciate this.
Post PCI thoughts
*It may not be that hard to do a complex PCI . But, it’s never easier to understand current cardiology literature that is supposed to raise our intellect , which has a direct relevance to patient welfare. Note, many crucial , high stake studies tend to play academic deceit games with linguistic and statistical hyperboles like Non Inferior , likely superiority , Never inferior , near equipoise , regression of hazards, virtual follow-up in real vs trial world etc , etc !
I can only hope for a better scientific world !
Reference
- Which is the best option for left main disease PCI or CABG ? Journal of Individual wisdom and evidence based conscience : Volume 1 Chapter 1- Coronary Intellect : Pages 0 to ∞ Jan 2018.
ORBITA trial : First let us do some harm . . . second , we shall . . !?
Posted in Cardiology -Interventional -PCI, Cardiology -Technology, Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology journal club, cardiology wisdom, Medical education, Medical ethics, Uncategorized, tagged ABUSE OF STENTS, ACC AHA ESC ORBITA GUIDELIES, CHRONIC STABLE ANGINA GUIDELINES, drsvenkatesan, HOW ORBITA TRIAL WILL CHANGE MY PRACTICE, INAPPROPRIATE USE CRITERIA AUC STENTS, LANCET ORBITA STUDY, ORBITA COURAGE BARI2D FAME 2, ORBITA IMPERIAL COLLEGE, ORBITA study, ORBITA TRIAL LANCET, ORBITA trial review and comments, ORBITA VS COURAGE, reviewing ORBITA trial study critically, TCTMD 2017 ORBITA, WAHT WE LEARN FROM ORBITA STUDY on November 6, 2017| 2 Comments »
Cardiologists at confused cross roads !
Perils of limited Intellect & Infinite greed
When not so appropriately trained cardiologists do Inappropriate things “use becomes misuse” . . . then, it won’t take much time for science to become total abuse. That’s what happened with the murky world of coronary stents .No surprise, it’s time to firefight the healers instead of the disease !
Now ,Comes the ORBITA study . Yes , it looks like a God sent path breaking trial that spits some harsh truths not only in cardiology, but also in behavioral ethics .Let us not work over time and hunt for any non-existing loop holes in ORBITA. Even if it has few, it can be condoned for sure as we have essentially lived out of flawed science for too long Injuring many Innocent hearts !
Yes , its enforced premature funeral times for a wonderful technology !
GIF Image courtesy http://www.tenor.com
Meanwhile, let us pray for a selective resurrection of stenting in chronic coronary syndromes and stop behaving like lesser professionals !
Postample
Extremely sorry . . . to all those discerning academic folks , who are looking for a true scientific review of ORBITA , please look elsewhere !
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