One Stent Bifurcation Techniques and Possible Bail Out Solutions Using Multimodality Imaging

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain MEDTRONIC SYMPOSIUM One Stent Bifurcation Techniques and Possible Bail Out Solutions Using Multimodality Imaging Author: Goran Stankovic, MD, Clinical Center of Serbia, Serbia BIFURCATION EDUCATION IS NEEDED Collaboration between EBC, Visible Heart Lab (VHL) and Medtronic initiated by EBC at 2012 meeting; There is a need to create: Educational program for fellows and young IC’s, aimed to help understanding bifurcation treatment techniques, complications and outcomes; The idea: A series of case scenarios, where trainee can learn step-by-step performance of different bifurcation stenting techniques and based on a combination of imaging technologies and computer simulation. OBJECTIVES Optimization of provisional one-stent bifurcation PCI technique and possible bail out solutions using multimodality imaging, including Visible Heart lab and OCT.

Culotte Technique with Endoscopic Visible Heart Imaging and OCT

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain MEDTRONIC SYMPOSIUM  - One stent bifurcation techniques and possible bail out solutions using multimodality imaging. Culotte Technique with Endoscopic Visible Heart Imaging and OCT Author: Jens Flensted Lassen, MD, PhD, Odense University Hospital, Denmark SUMMARY OF THE PROCEDURE 1. Implant the first stent. Provisional stenting is a philosophy starting with one stent The procedure develops stepwise. You can stop at any step keeping the procedure as simple as possible (But not too simple) Kiss is for positioning of the carina Pot is for correcting the proximal Part of the stent To ”deep” POT may crush the carina area, but is needed to correct the stent distortion KISS with short balloons makes room for a more proximal POT-Balloon placement. 2. Consider the need for a second stent T, TAP, and Culotte are all just techniques with a second stent and defined only by how deep the stent is placed, according to the side branch ostium. CONCLUSION The stepwise progression of the the provisional strategy makes it possible to stop at any stage when the result is satisfying.

One Stent Bifurcation Techniques and Possible Bail Out Solutions Using Multimodality Imaging – Introduction

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain MEDTRONIC SYMPOSIUM  - One stent bifurcation techniques and possible bail out solutions using multimodality imaging Introduction Author: Goran Stankovic, MD, Clinical Center of Serbia, Serbia BIFURCATION EDUCATION IS NEEDED Collaboration between EBC, Visible Heart Lab (VHL) and Medtronic initiated by EBC at 2012 meeting; There is a need to create: – Educational program for fellows and young IC’s, aimed to help understanding bifurcation treatment techniques, complications and outcomes; The idea: – A series of case scenarios, where trainee can learn step-by-step performance of different bifurcation stenting techniques and based on a combination of imaging technologies and computer simulation.

The Twilight Trial

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 3 The Twilight Trial: Ticagrelor with or without aspirin in high-risk patients after PCI Author: Vladimir Dzavik, MD, PhD, Toronto General Hospital, Canada TRIAL HYPOTHESIS In patients undergoing PCI who are at high risk for ischemic or hemorrhagic complications and who have completed a 3-month course of dual antiplatelet therapy with ticagrelor plus aspirin, continued treatment with ticagrelor monotherapy would be superior to ticagrelor plus aspirin with respect to clinically relevant bleeding and would not lead to ischemic harm. TRIAL OBJECTIVES Primary Objective: To determine the impact of SAPT (ticagrelor monotherapy) versus DAPT (ticagrelor plus aspirin) for 12 months in reducing clinically relevant bleeding (BARC 2, 3 or 5) among high-risk patients who have undergone successful PCI. Secondary Objective: To determine the impact of SAPT (ticagrelor monotherapy) versus DAPT (ticagrelor plus aspirin) for 12 months on major ischemic adverse events (all-cause death, non-fatal MI or stroke) among high-risk patients who have undergone successful PCI. CONCLUSION In high-risk patients who underwent PCI and were treated with ticagrelor and aspirin for 3 months without any major adverse (bleeding or ischemic) events, an antiplatelet strategy of continuing ticagrelor monotherapy resulted in: substantially less bleeding than ticagrelor plus aspirin without increasing ischemic events over a period of 1 year

Computational Stenting and Flow Simulations

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain MEDTRONIC SYMPOSIUM Computational Stenting and Flow Simulations Author: Yiannis S Chatzizisis, MD, PhD, University of Nebraska Medical Center, USA TAKE HOME MESSAGES Mixed reality is a combination of bench, ex-vivo and computational simulations Computational stent simulation is an accurate and feasible approach to study stent techniques and stent designs Always consider provisional bifurcation stenting “philosophy” with bail out conversion to TAP (or T)

The CABRIOLET Registry

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 3 The CABRIOLET Registry Preliminary Results - Coronary Artery Bifurcation Revascularization without kIssing ballOon infLation by rE-poT. Author: Francois Derimay, MD, PhD, Hôpital Cardiologique de Lyon, France THE CABRIOLET REGISTRY Multi center registry Aim: 500 complete re-POT All provisional stenting strategies Retrospective and prospective inclusions (end of inclusion in May 2019) Clinical FU 1 year minimum, up to 5 years CONCLUSION Preliminary datas of CABRIOLET registry but: Re-POT technique is safe and easy, available in a large range of bifurcation Pure sequential provisional technique respecting perfectly the physiological fractal geometry Perfect initial angiographic results Excellent clinical results at 1 year (2% of TVF) Final analysis in Mid 2020 (see you in the next EBC)

Nano Crush in Left Main

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 3 Nano Crush in Left Main Author: Gianluca Rigatelli, MD, PhD, Rovigo General Hospital, Italy NANO CRUSH FACTS 2014 : conceiving the technique and first application of the technique in LM and non-LM patients 2015 : application in shock patients 2017 : publication first preliminary series in Cardiovasc Revasc Med 2018 : publication of bench and computational fluid dynamic study in Cathet Cardiovasc Interv 2019 : Nano-Crush in Left main and cardiogenic shock in Cardiovasc Revasc Med 2019 : comparison between Nano-Crush and Culotte in Left main in Int J Cardiovasc Imag CONCLUSION Nano-crush stenting in Left Main showed improved long- term outcomes with low TVF, low mortality and 0% thrombosis compared to other double stent techniques Nano-crush stenting in Left Main provided easy and fast revascularization, low X-ray exposure and low contrast dose Nano-crush stenting can be an alternative to DK-crush in complex Left Main bifurcation disease

Lessons Learned from COBIS Studies 2004 to 2019

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 3 Keynote lecture: Lessons learned from COBIS studies: 2004 to 2019 Author: Bon Kwon Koo, MD, PhD & Young Bin Song, MD, PhD, Seoul National University Hospital, Samsung Medical Center, Seoul, Korea WHAT MAKES THE DIFFERENCE? Safer access: More trans-radial approach Better stents and better stenting technique Better PCI technique: Better kissing, NC balloon.... Better concept: Imaging guidance, SB relevance Better risk stratification: SB occlusion, risk stratification CONCLUSION COBIS registry started with bifurcation PCI patients since 2004 are s till ongoing with dedicated QCA core laboratory/CRO, independent st atistical analysis team and event adjudication committee. Results of COBIS studies expanded our knowledge on bifurcation tr eatment and improved the patients’ clinical outcomes. Ongoing COBIS III study will provide more insights on coronary bifu rcation lesions and their treatment.