left main disese | Dr.S.Venkatesan MD

Posts Tagged ‘left main disese’

What is the most important criteria for doing a PCI in CAD ? The secret 6th criteria !

Posted in Uncategorized, tagged acc aha guidelines, acs, cabg, cath lab, chronic stable angina, cleaveland clinic, coronay revascularisation, courage trial, cypher stent, des, euoropct, flow limiting lesion, gruentzig, jacc, jama, left main disese, mayo clinic, nejm, nstemis, paclitaxel, pci, primary pci, proximal lad, ptca, ravel, scai, sirius, sirolimus, stemi, stent, stenting, syntax score, taxus, tct md, triple vesseldisease, wisdom trial on May 4, 2009| 1 Comment »

Scientifically , the indication for coronary revascularisation should be based on following

Patient’s symptom ( more specifically angina , dyspnea is less important !)
Prov0kable ischemia ( A significantly positive stress test )
Signifcant LV dysfunction with documented viable myocardium & residual ischemia
A revascularisation eligible coronary anatomy * TVD/Left main/Proximal LAD etc ( *Either 1, 2 or 3 should be present in addition )
All emergency PCI during STEMI /High risk NSTEMI

Practically ,

A CAD patient may fulfill “Any of the above 5 “ or “None of the above 5” , but , if a coronary obstruction was revealed by coronary angiogram and if he fulfils The 6th criteria , he becomes eligible for revascualrisation

6th criteria

If the patient has enough monetary resources (by self ) or by an insurance company to take care of PCI /CABG *

*The sixth criteria overrides all other criteria in many of the cath labs .Of course , there are few genuine ones still fighting hard , to keep the commerce out , from contaminating cardiology !

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What is the hemodynamic impact on the left main blood flow when LIMA is grafted to LAD ?

Posted in cardiac surgery, Cardiology -Interventional -PCI, cardiology -Therapeutics, tagged cabg, left internal mamary graft, left main disese, lima on March 15, 2009| Leave a Comment »

CABG is tretment of choice for left main and complex proximal LAD lesions. So most patients get CABG in these situations.

The hemodynamic effects of LIMA graft on native left coronary artery can be tremendous and some times deterimental.

One of the consistent observation has been , the moment LIMA is bypasssed into distal LAD the antegrade flow through left main is reduced .This is still more significant if circumflex is also grafted .
For inital few weeks there is competition between LIMA flow and LAD flow and invariably LIMA wins , and native leftmain or LAD flow regresses and many times closes totally.
Some studies have observed accelerated left main and LAD atherosclerosis.
The native LAD and leftmain could be a source for thrombi and atheromatous debri and these migrate distally and have potential to block the LIMA entry point into LAD
The advantage of having a patent native left main and LAD is that if the LIMA graft occludes later on native circulation may assist.

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Some thoughts about left main disease : Why CABG will always prevail over PCI in left main disease ?

Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Uncategorized, tagged annlas of thoracic surgery, cabg, cardiac surgery, ctsnet, jacc, LAD, lancet, left main disese, left main stenting, left main vs cabg, lima, nejm, pci for left main, proximal lad, radial graft on March 6, 2009| Leave a Comment »

Why PCI in left main CAD is considered an inferior modality than CABG ?

CABG is superior to PCI for the simple reason it provides complete revascularisation virtually in all patients with LMCAD , while PCI is possible only in a fraction of patients with LMCAD.

If we take 100 patients with left main disease may be ten (At best !) would be suitable for PCI ! In other words PCI is contraindicated in vast majority of LMCAD by technical criteria alone , while there can never be a contraindication for CABG in patients with LMCAD.(Except when , comorbidity precludes surgery )

Why PCI in LMCAD difficult ?

It is dependent on technicalities

CABG does not tackle a lesion, it simply avoids it and by passes it ” No great brains required”

while PCI takes on the plaque frontally , in the dangerous terrain of left main artery itself !

so, much caution, planing , logistics are required . Further , if there is a complication there is a potential

for catastrophe as the only supply line is cut off . This is the reason , cardiologists were worried to try this on

unprotected left main. (Protected LMCAD refers to left main disease following CABG wherein atleast LAD or LCX is grafted )

Points to ponder in LMCAD

PCI is suited for isolated discrete LM disease.In realty this is seen in less than 5-8 % CAD.
LMCAD is very often associated with critical and multivessel distal CAD . So these patients will be candidates for CABG.
Left main ostium or LAD ostial involvement makes PCI a tougher exercise
Calcification is more common in LMCAD that again makes PCI difficult.

The following article in Feb 2009 is a major blow for proponents of PCI for left main

http://circ.ahajournals.org/cgi/content/extract/119/7/1013

http://content.onlinejacc.org/cgi/content/abstract/51/5/538?ijkey=84c977d189e84327c3abbd4c1228de17dd99048a&keytype2=tf_ipsecsha

Final message

Conquering left main disease is an interventionist’s ultimate dream.
But, before that they have to tackle the bifurcation lesions .This is of vital importance, because 2/3 rd of left main patients have some form of bifurcation lesions. Current techniques , hardware and outcomes are far below the idealistic solutions in bifurcation lesions.
Till that time , CABG would remain the only choice for all , but for a small fraction of isolated left main disease where PCI may be possible.

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What is the incidence of insignificant left main disese ? How will you manage it ?

Posted in Cardiology -Interventional -PCI, cardiology- coronary care, Cardiology-Coronary artery disese, Hemodynamics, Uncategorized, tagged 70% or 90%, abrams, acc aha, acs, coronary artery diameter stenosis, coronary artery disease, coronary cross section, cypher, des, distal left main, ellis, flow limiting lesion, insiginifcant left main, LAD, left main disese, left msin 40% lesion, non flow limiting lesion, pci, ptca, scai, tapering left main, vulnerable plaque on March 6, 2009| Leave a Comment »

Left main coronary artery disease (LMCAD) often evokes a panic reaction among cardiologists .Not every LMD deserve that re. To label it as significant, we have a criteria , that is 50% diameter stenosis. So what you do , for a tapering or narrowed left main with 40% stenosis. Isolated insignificant left main is rare *, but real incidence is not known. LMCAD is most often due to , atherosclerosis of left main coronary artery without limiting the flow.

What are the options ?

Leave it alone, with intensive medical management assisted by high dose statin(80mg)
Elective PCI with stenting , even though the lesion is not significant.

*If associated LAD or LCX is there decision making is easier .

How significant is a coronary stenosis ?

The significance of a coronary lesion with reference to “lumen diameter obstruction” is basically flawed. The significance of a coronary stenosis, by tradition is based on it’s hemodynamic impact ,right from the CASS days in early seventies.Unfortunately our mind set has not changed even after realising non obstructive – sub critical lesion is more prone for acute coronary syndrome. Is it not ironical to call a 40% lesion a non significant one !

So, the significance of coronary stenosis is two fold.

Hemodynamic significance
Clinical and pathologic significance

The former predisposes to often chronic stable angina, later likely to result in ACS.

How will you approach a apparently insignificant left main disease ?

A 40 % lesion in left main is hemodynamically not significant , but pathologically very significant.It needs intensive treatment. Plaque passification with medical approach is first choice.If the lesion morphology is eccentric, has irregular margins or involves LAD or LCX ostium doing a PCI or even a CABG is to be considered in spite of the lesion is hemodynamically insignificant .

Why , PCI is considered “not appropriate” for less tighter lesions , even though these lesions have great clinical significance ?

The answer is simple, The risks and the potential cost are more than the benefit !

And further , stents are not innocuous devices either , they always carry a risk of sudden occlusion as like a sub critical lesion !

Answer to the title question

True incidence is not known . Our experince (Class 1 c evidence) would suggest Left main disease constitutes up to 10 % of CAD.Among this one third would be hemodynamically insignificant

Don’t panic when you diagnose a left main disease in routine coronary angiogram : It may cost you a life !

Posted in Cardiology -Interventional -PCI, cardiology- coronary care, Uncategorized, tagged acs, atherosclerosis, cardiology, cath lab, chronic stable angina, coronary artery disese, drsvenkatesan, europcr, intervenional cardiologists, left main, left main disese, pci, ptca, tct md on August 25, 2008| Leave a Comment »

Left main coronary lesions are fairly common during routine coronary angiogram.These may be a critical or a innocuous lesion.The word “left main” triggers a sort of alarm reaction to many cath lab staff as well as the cardiologists and surgeon.Many times, these left main lesions are detected in patients with chronic stable angina who have stable symptoms. Left main disese has not been graded clearly in literature . Often it is perceived , any lesion in LM is serious.

There is an unwritten rule, rather a medical compulsion to take a patient with left main disease for emergency CABG ( Now some centres ,emergency PCI) .Some institutions make it a rule these patients are posted in the next available slot in the theatre.

The basic question we raise here is “Should we consider all left main disease as an emergency”?

Not really , especially when it occurs in a stable angina .One can wait , buy some time to fully evaluate and prepare the patient and may be the patient can be posted as an elective case. It is a well recognised fact that, CABG carries adverse outcome when done as an emergency procedure. This is primarily due to inadequate pre op work up and resultant complications. It is also well known , surgical back up team may not be available in full strength in odd hours .

This post is to convey the message , that left main is a serious disease but that doesn’t mean it should elicit a panic reaction and be taken as an ultra emergency . There has been many morbid and fatal outcomes in many hospitals due to this apparent pseudo emergency !

Note* 1.Left main disease during acute coronary syndrome is to be seen in different perspective.2.Some of the proximal LAD lesions are so tight and could be more significant than left main lesions.

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Dr.S.Venkatesan MD

Expressions in cardiology

Posts Tagged ‘left main disese’