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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 Shahurmil.shah@cims.me
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
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Volume-5 | Issue-51 | February 5, 2014
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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Healthy Heart
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Volume-5 | Issue-51 | February 5, 2014
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
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Heart Surgeon
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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.
Volume-5 | Issue-51 | February 5, 2014
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Volume-5 | Issue-51 | February 5, 2014
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