Revisiting October’s Insights: Coronary physiology and imaging in preventing MACE after intervention

Functional assessment of coronary arteries and microcirculation is a milestone in personalized approach to ischemic heart disease management. The importance of coronary artery imaging during PCI was highlighted during ESC2023.
During Prevention & Intervention Shrilla Banerjee, Michał Hawranek, Vijay Kunadian, Valeria Paradies and Łukasz Pyka discussed current state-of-the-art approach to coronary physiology assessment and imaging.
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Vijay Kunadian:   One case, and people always ask: ‘Which is the case that stuck with you?’ Every case is so important, and I’ll never forget this case, which I did a long time ago. I’ve written it up in many, many publications.

A 59-year-old lady, again a woman, late presenter. She didn’t call for help, and the husband comes back from work, looks at her, and thinks: ‘You’re not well. I’m going to call the ambulance’. And of course, by the time it was 12 hours from symptom onset, and she’s in cardiogenic shock. 

It was Monday, I was on call for cath lab. And the patient comes in a really bad state, 42/60 mm of systolic blood pressure. We do an angiogram, and this is what we find: a long, which is clearly, it’s a thrombus extending from the left main into the circumflex.

So, at the time, we were probably wondering whether we should use thrombus aspiration or not. But I didn’t really want the thrombus to extend further, so I went against, not against, but individualized tailoring therapy, and I thought I’m going to use a thrombus extraction. And we extracted the thrombus out. And then when you look at the angiogram, it looks pretty clear from some of the cross-section images that should I show you, we have the intima-media, everything in perfect condition. And then you’re wondering: ‘She’s a woman, is it that the thrombus comes from somewhere else?’ And the patient wasn’t actually getting better. Blood pressure was still 60, ST all over the place, and then we decided to image her. And then we found, in fact, she had a plaque erosion at the very ostium of the left main. 

I’m not again nail the point: common things are common. 

She didn’t have embolia coming, it’s a plaque. If I didn’t do the imaging, we would have missed that plaque erosion, and she wouldn’t have been treated. And it’s interesting, and in women, everything is different. And I can say I’m a woman-sensitive, and you might think: ‘Why did you stent that?’ And I just want to seal that plaque. I didn’t want the thrombus accumulating again. As soon as we did that, all the ST came down, and she kind of woke up, and you know, ‘Where am I?’ etc., etc. 

So, this is just to emphasize again, common things are common. And it’s really important that we don’t just stop at the angiogram, but go further and investigate these patients.