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ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 This case is brought to you by the ROYAL BLACKBURN HOSPITAL

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Today’s Team Claire Sheridan Michael Hindle Asma Patel Katie Shah (Nurse) (Physiologist) (Radiographer) (Nurse) Scot Garg John McDonald Ravi Singh

Catchment population of 520,000 Non-surgical centre with a PCI service which started in 2010 2 Cath labs (Siemens soon to be Philips) Royal 4 PCI operators Blackburn Volume 680-700 cases Hospital • 35% Elective / 65% ACS split • Day case rate for elective PCI 85% • No on-site PPCI –patients transferred 24/7 to Blackpool (32 miles away) • CTO service (with Bridgepoint) volume – 50 cases • Radial rate >97% 24/5 PCI on-call (not for primary PCI)

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 STAGED PCI Patient MC

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 q MC – 49 year old male Risk factors: Smoker, hypertension, T2DM, family history Previously well with no prior CV history 20/10/2018 - Anterior STEMI treated with PPCI to LAD (2 DES) with IVUS @ BVH

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Referred to Blackburn for management of bystander disease and follow-up

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Clinical Status Post STEMI Exertional dyspnoea up inclines Echo Moderate LV impairment (hypokinetic inferior wall, akinetic anterior wall & normal lateral wall) Dobutamine Stress echo Viability in hypokinetic inferior segments No viability in anterior wall Ischaemia in infero-lateral wall

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Polling Question 1 What is your strategy for bystander disease post culprit artery PCI? a. Don’t bother with anything unless symptomatic b. Treat all lesions at the time of index PCI c. Treat all lesions prior to discharge d. Elective PCI only if non-invasive assessment is positive Vote now! e. FFR/iFR guided elective PCI irrespective of symptoms

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Plan iFR +/- FFR and IVUS guided PCI to the right coronary artery using Tri-registration Rationale Young male with an infarcted anterior wall and extensively diseased RCA, supplying a large territory of viable myocardium Use of technology to minimise excessive stenting and prevent full metal jacket Challenges Complete revascularization or symptom driven PCI post STEMI? Assessment of bystander disease Timing of staged PCI? Invasive assessment of tandem lesions

ADVANCED CARDIOVASCULAR INTERVENTION ACI 2019 Polling Question 2 How do you proceed with a positive FFR/iFR in a vessel with multiple tandem lesions? a. Repeat it several times and hope it becomes negative or falls in the grey zone b. Stent all the lesions and don’t repeat the FFR/iFR c. Stent the most severe lesion and repeat the FFR/iFR d. Use FFR/iFR pullback and treat the area with the largest step-up e. Use iFR pullback with co-registration to help you decide which lesion to stent Vote now!