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Practical approaches and novel technology to optimize left main procedure outcome 12th EBC meeting, October 14-15, 2016 Rotterdam Session Objective 1. To learn about contemporary treatment strategies for LMCA bifurcation lesions and to reflect on practical cases; • SB Access – Reverse J, Venture catheter, Crusade catheter • SB protection – Jailed wire technique, jailed balloon, predilatation • Stent techniques – Provisonal T, crush, culottes, kissing, TAP, mini-crush, DK-crush… • Stent optimization – Proximal optimization technique, final kissing ballooning… • Imaging, physiology – IVUS, OCT, FFR Courtesy of HC. Gwon Session Objective 2. To learn from state-of-the-art imaging on stent behavior in bifurcation Provisional stenting Culotte The visible heart DK Crush Reconstruction from CT scan Session Objective 3. To learn about usefulness of novel generation DES dedicated to large vessel treatment Platinum Iridium Core Cobalt Alloy Outer Core Wire Technology used to create sinusoid-formed wire Core Wire Technology enables: • Increased deliverability • Thinner struts with enhanced radiopacity • No compromise to structural strength Onyx xlv provisional LM bifurcation: final result Selection of treatment for left main: Current guidelines and clinical aspects to be considered G. Stankovic, MD, PhD LEFT MAIN STENTING • LMCA disease presents in 5-7% of patients undergoing coronary angiography1 • The left main is a critical vessel supplying 75-100% of left ventricular cardiac mass1 • Medical management alone results in a high mortality rate, further requiring revascularization2 Images from: Kapur P et al, Europen Congress of Radiology (ECR) 2012 1. Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50. 2. Bittl JA, He Y, et al. Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients with Unprotected Left Main Coronary Artery Disease Circ. 2013; 127: 2177–2185. 6 EVOLUTION OF ESC GUIDELINES FOR LEFT MAIN PCI PCI for distal LM: IIb | 2010 Focus on lesion type and severity: • PCI is always inferior to CABG for LM lesions of all types • PCI is NOT recommended for MVD, SYNTAX score ≥33 PCI acceptance | 2013 PCI has prominent role | 2014 | 2016? Focus on lesion type and patient surgery risk: Focus on lesion severity: • PCI is recommended when it is 1 lesion in patient with high risk of surgery • PCI is NOT recommended for MVD in low surgery risk patients • PCI is recommended for simple lesion, SYNTAX ≤22 • PCI should be considered for intermediate lesions • PCI is NOT recommended for complex lesions, SYNTAX ≥33 7 60% OF LEFT MAIN PATIENTS ARE ELIGIBLE FOR PCI1,2 Multi-vessel disease comprises a high proportion of low-intermediate SYNTAX score patients3 Breakdown of left main patients by SYNTAX score2 100% 90% 80% SYNTAX ≤ 22 32% SYNTAX > 32 40% SYNTAX 23–32 28% 70% 60% LM + 3VD 50% LM + 2VD 40% LM + 1VD 30% LM Isolated 20% 10% 0 LOW SYNTAX 0 – 22 1. 2. 3. INTERMEDIAT E SYNTAX HIGH SYNTAX 23 -32 >32 Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619 Morice MC, Serruys PW, et al. Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial. 2010; 121:2645–2653. Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50. LM PCI OUTCOMES IMPROVE WITH NEWER TECHNOLOGY PCI has gained acceptance as a primary treatment modality for left main disease, especially for lowto-intermediate SYNTAX lesions1 Outcomes in left main PCI continually improved with improved stent platforms3 MACE HR (95% CI) p-Value n BMS 0.33 (0.23–0.47) < 0.05 260 First-generation DES 0.53 (0.35–0.80) < 0.05 394 Second-generation DES 1.01 (0.68–1.49) NS 4704 CABG Better PCI Better 1. Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619. 2. Morice MC, Serruys PW, et al. Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial. 2010; 121:2645–2653. 3. Park SJ, Ahn JM, et al. Temporal Trends in Revascularization Strategy and Outcomes in Left Main Coronary Artery Stenosis: Data From the Asan Medical Center-Left Main Revascularization Registry. Circ Cardiovasc Interv. 2015;8:e001846. 4. Includes n = 51 zotarolimus-eluting stent. 9 CHALLENGES OF LEFT MAIN PCI • Up to 80% of left main lesions involve the bifurcation1 • 75% of left main diameters are 4.00–5.75 mm1 • Aorto-ostial issues of disease within 3 mm of the ostium can be fibrotic, calcified and rigid • The diameter of the LMA can range from 4.0 to 7.4 mm limiting device selection – Large vessels tend to have large side branch openings which provide significant blood flow to the myocardium and may have involved disease Images from: Kapur P et al, Europen Congress of Radiology (ECR) 2012 Fajadet Eur Heart J 2012; 33: 36-50 1. Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619. 2. ShandJA, et al. A Prospective Intravascular Ultrasound Investigation of the Necessity for and Efficacy of Postdilation Beyond Nominal Diameter of 3 Current Generation DES Platforms for the Percutaneous Treatment of the Left Main Coronary Artery Catheterization and Cardiovascular Interventions 84:351–358 (2014). 10 LEFT MAIN BIFURCATION RHEOLOGY Left main bifurcation flow dynamics favor provisional stenting Atherosclerotic lesions tend to form in areas of low shear stress1 Atherosclerosis is accelerated along the lateral wall of the left main, close to the bifurcation3 Left main bifurcation physiology is favorable towards provisional stenting In the left main bifurcation, wall shear stress is typically low on the lateral walls and high at the carina2 The carina is frequently free of disease3 EBC consensus4: Provisional stenting is the preferred strategy in LMCA bifurcation lesions5 1. 2. 3. 4. 5. Ku. Arterioscl . 1985; 5(3): 293–302. Soulis. Hippok. 2014; 18(1): 12–16. Fajadet. Eur Heart J . 2012; 33: 36–50. Lassen. EuroInterv. 2014; 10:545–60. Per EBC consensus a two-stent technique is preferred in case of significant proximal LCX disease. 11 BIFURCATION TECHNIQUE SELECTION • Stenting Technique selection1 – – – – – Plaque distribution Size of the main and the side branch Severity and length of the side-branch lesion Bifurcation angulation Operator experience/expertise • A single stent strategy whenever possible may help to reduce major adverse cardiac events (MACE)2 • Among two-stent techniques, there seems to be no difference between the treatment approaches2 1. Fajadet J, Chieffo A. Current management of left main coronary artery disease. European Heart Journal (2012) 33, 36–50. 2. Palmerini T, Marzocchi A, Tamburino C, et al. Impact of bifurcation technique on 2-year clinical outcomes in 773 patients with distal unprotected left main coronary artery stenosis treated with drug-eluting stents. Circ Cardiovasc Interv 2008;1:185-92. 12 Take-home message Provisional LMCA stenting technique: step-by-step 1. Both branches are wired starting with the most difficult one 2. MB is stented (stent sized according to MB distal reference) and SB wire is jailed 3. The stent is post-dilated using the Proximal Optimization Technique (POT) to maximize stent apposition 4. Stent is now well apposed proximally, while the SB is partially covered by scaffolding 5. MB wire is pulled back and re-inserted through the most distal strut of the SB opening scaffold 6. Jailed wire is removed and re-inserted in the distal MB (with a formed loop at the distal end) 7. The Kissing Balloon inflation is done to optimize side branch flow and access 8. Final result (if suboptimal, can then place additional stents) Louvard & lefèvre. Eurointervention 2011;7:160-163 Visible Heart® & Resolute Onyx™ DES Visible Heart® Resolute Onyx™ • Powerful imaging tool for • Improved deliverability studying bifurcation stent and conformability behavior based upon the flexible • Visualization for studying design: continuous new bifurcation sinusoidal technologies techniques and (CST); complications • Enhanced radiopacity and thinner struts (Core Wire)