healthy heart (vol-5, issue-51) february, 2014 - dr. urmil shah-4 - … · 2019. 5. 12. ·...

Volume-5 | Issue-51 | February 5, 2014

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Healthy HeartHonorary Editor :

Dr. Urmil Shah

From the desk of Editor:

Newer technology and research is the key to field of medicine including cardiology. In this issue of Healthy Heart two topics covered are classic example of how newer innovation is helping doctors to manage their patient in a better way day by day. When I was doing my DM residency absolute indication of CABG was patient with left main disease but in 2014 with availability of newer hardware and technology the whole concept of managing left main disease is changed. Patient with stable coronary artery disease where anatomical information about coronary artery blockage which is obtained by conventional coronary angiography with known limitation of physiological imaging techniques; interventional management in this subset of patients does create many doubts and discrepancy. A simple diagnostic technique with name of Fractional Flow Reserve (FFR) and Intravascular Ultrasound (IVUS) is very useful in decision making regarding intervention in many patients.

- Dr. Urmil [email protected]

Management of Left Main Coronary Artery DiseaseThe third case of Angioplasty in the world

done by Dr. Andreas Gruentzig in 1977

was left main stenting. Patient died after 4

month of procedure a time of No Drug

Eluting Stent, No Antiplatelets, No IVUS.

CASS(Coronary Artery Surgery Study)

study shown significant better outcome

of CABG compare to medical arm. Since

then for many years, CABG has been main

stay for treatment of left main disease.

Due to improvement in technology and

availability of new generation drug eluting

stent many of the patients with left main

disease can be managed with good mid-

term outcome compared to CABG.

Patients with left main disease who have

already undergone CABG with one graft

patent (Protected Left Main) is always

m a n a g e d w i t h i n t e r v e n t i o n .

Management of unprotected left main

disease (without previous CABG) will be

discussed in this article. Left main disease

can be classified into isolated left main

disease (approximately 15%), left main

with 1 vessel, 2 vessel and 3 vessel

disease. Left main disease can also be

classified according to location of lesion to

ostial, mid and distal left main disease.

There is great limitation of conventional

angiography for diagnosis and managing

left main disease. Intra Vascular Ultra

Sound (IVUS) and Fractional Flow Reserve

(FFR) are very important in deciding

Figure 1

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Cardiologists Cardiothoracic & Vascular Surgeons Cardiac Anaesthetists

Neonatologist and Pediatric IntensivistPediatric & Structural Heart Surgeons

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severity of lesion. IVUS is mandatory pre

and post to decide stent size and post

stents opposition to vessel wall.

The aim of any intervention including left

main intervention should be good

immediate success with acceptable risk

as well as good long term outcome. Many

factors are important both clinical and

anatomical like presentation, age of the

patients, LV function, risk of bleeding ,

long term out come data ,cost, patients

preference, availability of skilled

operator and well equipped center to

recommend line of management. For

choosing CABG and angioplasty, syntax

score based on Angiography is very

helpful. With syntax score less then 33

mid term outcome (5 to 6 years) for CABG

and stenting with first generation drug

eluting stent is same as shown in syntax

study and also in meta-analysis, so

angioplasty should be offered. For >33

syntax score, CABG is better than

angioplasty and should be offered

(Figure - 1). Clinical syntax score and

global risk score which includes clinical

and biochemical parameters can be of

additional value in deciding line of

management. New ongoing trial EXCEL

study with new third generation DES

(Xience) with syntax score <33 may give

better guidance for choosing between

CABG Vs. Angioplasty .

Ostial or mid left main disease is manged

with single drug eluting stents of main

vessel with provisional stenting of other

branch, where as distal bifurcation lesion

is managed with two stents using either

mini CRUSH or CULOTTE(Figure - 2).

Plasty is done through femoral route and

pre and post angioplasty IVUS by

experience person is pre requisite in left

main intervention.

European guide line published in 2013 as

shown in figure below will give a clear

idea for managing stable left main

disease (Figure - 3).

It is advocated to discuss all left main

cases with multi vessel disease with heart

surgical team and surgical risk should

also be taken into account before

recommending patient with left main

disease. In conclusion, my current

opinion in decision making would be

CABG for left main disease with syntax

score >33 if CABG is not contraindicated

or predicted risk of CABG <10 %. With

syntax score <33 Angioplasty with drug

eluting stent with IVUS is recommended

except technically difficult lesion CRF,

diabetes.

Figure – 2. Distal Left Main Lesion – Management

Figure - 3

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Healthy HeartVolume-5 | Issue-51 | February 5, 2014

Though coronary angiography (CAG) is

considered to be gold standard for

diagnosis and management of Coronary

Artery Disease over years, there are

several definite limitations. In patients

with acute coronary syndrome, coronary

angiography still can give definitive line

of management as far as intervention is

concerned with help of cl inical

parameter, ECG and bio marker. But in

stable angina patient there are many

doubts, controversies and discrepancies

regarding definitive interventional

management with help of only coronary

angiography as it gives more of a

anatomical information and not

physiological information. Non invasive

test like thallium scan, stress test, stress

echo done to know evidence of ischemia

in patient with stable angina especially

with left main disease, multi vessel

disease, lesion of intermediate severity

(50 to 70 %), LBBB, with LV dysfunction

has several limitations . One has to be

reasonably sure leaving this kind of

patient on medical management; at the

same time one should not be not doing

intervention on patients which is not

g o i n g t o b e n e f i t t h e p a t i e n t .

Physiological assessment of lesion

especially of intermediate severity and

left main with the help of FFR (simple

pressure wire which measures pressure

difference across the lesion with

maximum hyperemia with adenosin) has

been found to be very helpful in decision

making along with coronary angiography

inside Cath Lab.

DEFFER study showed that deferring

angioplasty in a patient with insignificant

lesion (FFR more than 0.8) has same

incidence of MI and death at the end of 5

years and so can be considered safe in the

long run. Deferring angioplasty helps to

reduce the cost to the patient and

reducing extra risk of the

intervention. FAME-1 (FFR

v s . A n g i o g r a p h y i n

Multivessel Evaluation)

study of 1000 patient with

multi vessel disease was

conducted for FFR guided

(with FFR < 0.8) angioplasty

over only angiography

guided angioplasty were

studied. FFR guided intervention was

associated with 39 % less incidence of

death MI and repeat procedure with less

need of stent, hardware, dye. Thus FFR

guided therapy was not only cost

effective but cost saving.

Recently published FAME-2 study clearly

demonstrated that patient with FFR < 0.8

(physiologically significant lesion) doing

FFR & IVUS - Diagnostic Techniques (Useful Adjuvant to Coronary Angiography)

Figure-1 : FFR is a technique to assess the functional significance of a coronary stenosis. FFR is independent of changes in heart rate, blood pressure or prior infraction, and takes into account the amount of viable myocardium and the contribution of collateral blood flow.

(Figure-2)


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angioplasty is better than medical arm in

long run as it reduces the future urgent

need of revascularization. Thus FFR

avoids needs of intervention – resources

and cost to the patient at the same time

improves quality of life and improves

outcome in the long run. If one includes

extra cost of urgent revascularization and

outcome one can say that using FFR along

with angiography in patient with stable

angina is not safe but cost effective also.

In patient with multi vessel disease

decision regarding which vessel should

be stented is best done with FFR which is

lesion specific where stress thallium and

stress echo is of limited value. This is the

reason why FFR is class-IIa indication

according to AHA/ACC 2011 guideline in

patient with intermediate lesion (50 to

70 %) unstable angina not having

symptom and positive non invasive

imaging. European PCI guideline 2013

classified FFR as class-I A indication for

detection of ischemia related to lesion

where objective evidence of ischemia is

not available.

Intravascular ultrasound (IVUS) as it gives

more precise information regarding

vessel size and composition of plaque is

very much essential while doing complex

interventions like left main disease,

bifurcation disease, calcific disease.

The reason for early stent thrombosis a

potentially dangerous complication is

partly because of under expansion of

stent where IVUS has an important role.

Mata-analysis of various RCTs of IVUS

Guided vs Angio Guided BMS and drug

eluting stents implantation clearly

showed better outcome in form of

overall MACE (Major Adverse Cardiac

Events), angiography restenosis less

stent thrombosis with IVUS guided

Angioplasty.

Thus FFR is very useful adjuvant to

conventional agniography and is

considered as gold standard in dealing

with stable angina patient with inter

mediate lesion (50 to 70 % lesion) and in

patient with multi vessel disease as it

improves MACE. Whereas IVUS is

essential to improve outcome and

reduce complication in complex coronary

intervention.

(Figure-3) (Figure-4)

(Figure-5)

(Figure-6)

(Figure-7)


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Healthy HeartVolume-5 | Issue-51 | February 5, 2014

In Association with

Gujarat Cardiothoracic Surgeons Club

Ahmedabad Aortic Conclave (AAC)

JICJoint International Conference

2014CIMS

CIMS Hospital, Ahmedabad

Around 200 Cardiac Surgeons &Anaesthetists attended the conference

® First of its kind live workshop on Aortic valve repair in India

® First of its kind Cardiac conference in India to be live webcasted all over the world

® First of its kind of conference to have wetlab for new and aspiring cardiac surgeons

who get guidance from expert from the field of Aortic Surgery

® Video Launch of a very new techologically advanced Aortic sutureless valve in India

Cardiothoracic & Vascular Surgeons

Dr. Dhiren Shah +91-98255 75933

Dr. Dhaval Naik +91-90991 11133

Dr. Saurabh Jaiswal +91-95867 25827

Pediatric & Structural

Heart Surgeon

+91-98250 44502

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Dr. Hemang Baxi Dr. Vineet Sankhla

Congratulations to

Dr. Hemang Baxi and Dr. Vineet Sankhla for receiving the prestigious FESC

(Fellowship of European Society of

Cardiology) Award

AAPI “GLOBAL LEADERSHIP AWARD”AT THE HANDS OF

HONORABLE CHIEF MINISTER –

Hon’ble Shri NARENDRA MODI

CIMS HOSPITAL CONGRATULATES

DR. KEYUR PARIKH


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We bring in among the first in WorldRadiotherapy Versa-HD (Elekta) in Asia Pacific

Linear Accelerator, Versa HD

Uniqueness of CIMS Radiation Centrenn Agility- High focus 160 leaf MLC, newly launched by Elektan APEX DMLC - A High definition 2.5mm leaf width for brain tumorsn First FFF mode treatment in Asia by Elektan 3 times higher dose rate than any other normal Linac dose raten Hexapod-6 dimensional motion correction by robotic couchn Minimize the treatment setup error by correcting 3 rotational & 3

transverse motions during the treatment.n Active Breathing Coordinator™ System

q Exactly track the position of moving target like lung tumor because of breathing motion & reduce the dose to normal tissue.

n 4D SYMMETRYq SymmetryTM provides acquisition and in line reconstruction of 4D

volumetric data, utilizing unique patented technology for sorting each projection image into a phase based bin. This sorting occurs by reviewing the moving anatomy within the projection images and calculating a respiratory trace directly from the internal anatomy

First Versa HD Linear Accelerator by Elekta in Asia

To complete its offer of a super multispecialty hospital, CIMS is proud to offer a new service, by introducing Radiation

Oncology Center. This upcoming set up is all geared up to be open to service by end of March 2014.

Equipped with the latest state-of-the art equipment and supported by highly qualified and dedicated oncologists, Care Institute of Medical Sciences is all set to become one of the desired destinations of cancer patients from across the country and specifically catering to the population of Western India.

CIMS

Dr. Devang C. BhavsarMD

(M) +91-98253 74411

Consultant Radiation

Oncologist at CIMS Cancer

Center. Associate Professor

and post graduate teacher

at Gujarat Cancer &

Research Center. One of

the pioneers of Image

Guided Radiotherapy

technique in India. Special

interest in Neuro Oncology,

Prostate Cancers & SRS.

Very active in social

activities like cancer

awareness camps.

Dr. Kinjal R. JaniMD(M) +91-98255 76533Consultant Radiation Oncologist at CIMS Cancer Center. Gold medalist for subject ENT in MBBS. Received the first rank award from Gujarat Cancer Society in 2005. One of the highest experience of Image Guided Radiotherapy in India. Special interests in Head & Neck Oncology, Prostate Cancers & Breast Cancers. Very active in social activities like cancer awareness talks and camps.



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