LAD CTO and LM treated with TAP

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain TIPS AND TRICKS IN BIFURCATION PCI - THE SYNERGY BETWEEN EBC AND ASIA LAD CTO and LM treated with TAP Author: Jaskaran Singh Dugal, MD, Jehangir Hospital, India HISTORY 40 year old patient Had anterior wall MI 10 years ago. He was given thrombolytic therapy with STK and subsequently continued on medical management Now presented with retrosternal pain and DOE with minimal exertion ECHO showed anterior wall RWMA hypokinesia EF 50% Risk profile - Hypertension, Hyperlipidimia Syntax Score 30 JCTO score - 2 PLAN Address CTO antegrade/retrograde • LCX/OM Bifurcation LAD/LCX/LMCA Bifurcation LAD/diagonal What Technique? 

Unprotected LM Trifurcation Lesion treated as two sequential bifurcations

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING Unprotected LM Trifurcation lesion treated as Two sequential Bifurcations using two different stenting techniques Author: Parminder Singh, MD, DM, PGI Chandigarh, India CASE OBJECTIVE To discuss and learn: Management of LM trifurcation lesion in ACS - simplifying a multiple stent strategy CASE PRESENTATION Patient Demographics:    27 year old     Male , a cab driver Clinical History:    Recent onset angina class III , one episode of rest angina   Dyspnoea on exertion both for last - 25 days Risk Factors:    Hypertension   Family History of CAD : Father, Paternal Uncle, Paternal Grandfather Diagnostic Tests:     ECG revealed ST depression in V3-V6   2D Echo - Normal LV FuncDon , No RWMA ,Normal valves   TROPONIN - Elevated LEARNING POINTS Distil left main trifurcation is a complex lesion - Op2mal PCI strategy - not well defined Basic rules of bifurcation lesions can be applied to trifurcation. Keep it simple:  Single stent > 2 stent > 3 stent strategy preferred. Simplified by treating trifurcation as two sequential bifurcations, especially if three stent strategy is planned . By combining two stenting techniques for LM trifurcation ,good result can be achieved quickly and safely ,esp. in ACS. IVUS guidance is helpful in optimising procedure results as in other left main lesions.

True Lumen Sandwiched in Neocarina

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING True Lumen Sandwiched in Neocarina Role of IVUS in LM CTO Author: Juan Luis Gutierrez Chico, MD, PhD, Cardiac Care - Cardiovascular Heart Centre Marbella, Spain CLINICAL PRESENTATION 54 y.o. male pt Angina CCS II TTE: LVEF 72%, no WMA SPECT: Anterior perfusion defect on exertion TAKE HOME MESSAGE Any subintimal course around carina: alert Importance of imaging to solve complications Subintimal shift?  -->Plaque shift  --> Carina shift  --> Subintimal shift Stent the entry & exit points to subintima

How to treat recurrent lmca instent restenosis

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING How to treat recurrent lmca instent restenosis Author: Jo Dens, MD, PhD and Daan Cottens, MD, hospital Oost-Limburg Genk, Belgium CASE PRESENTATION Male, 71 years old Presenting symptom: – Stable angina CCS 2-3 Cardiovascular risk factors: – Ex-smoker, DM +, AHT +, dyslipidemia + Medication: – Acetylsalicylic acid 80mg 1dd, clopidogrel 75mg 1dd, atorvastatin 10mg 1dd, lisinopril 20mg 1dd, bisoprolol 5mg 1dd, metformin 850mg 3dd, gliclazide 60mg 1dd, allopurinol 300mg 1dd, sublingual nitrates as needed Medical history: 1991: Myocardial infarction R/ CABG LIMA>L1cx ; RIMA>distal RCA                                                         4/2017: Stable angina (medina 1-1-1 severe distal LMCA bifurcation stenosis) + D1 4/2017: PCI culo[e LMCA (TRYTON) + PCI D1 12/2018: Stable angina CCS 2: in-stent restenosis LMCA 12/2018: PCI LMCA – OCT guided stent optimization + drug eluting balloon SUMMARY In-stent re-restenosis remains a challenging issue Recurrence rate is high (> 5%->20%) OCT guided revascularization is preferred Different options... High pressure balloons/cutting balloons Intravascular lithotripsy Laser In-stent rota... CABG

Extreme Left Main Stem Calcification

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING Extreme Left Main Stem Calcification: Rotashock combination therapy Author: Peter O'Kane, MD FRCP, Royal Bournemouth Hospital, UK CLINICAL PRESENTATION 79 year old lady Unstable angina, Troponin 250, eGFR 38 Exertional dysopnea for several months Echo: LVEF 45%with akinetic apex but good regional wall motion elsewhere PCI STRATEGY 7F EBU3.5 Guide RT wire LAD & SB wire LCx Sapphire 2.0x20 balloon not cross LAD •Rotational atherectomy 2 stent technique - culotte of DK Crush • IVUS guided throughout

A left main distal trifurcation lesion: what did I do

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING A left main distal trifurcation lesion: what did I do Author: Shih Hung Chan, MD, PhD, National Cheng Kung University Hospital, Taiwan PATIENT CHARACTERISTICS A 49-year-old male had hypertension and hyperlipidemia. He had already received percutaneous coronary intervention twice for non-ST elevation myocardial infarction and unstable angina pectoris in the past few years. This Ame, he presented with crescendo angina for 1 month. Renal function was normal. TREATMENT STRATEGIES LV assistance device: nil Debulking/plaque modification: No marked calcification: not needed in the beginning In case needed, considering cutting balloon, scoring balloon,or rotational atherectomy     Intravascular image: Definitely needed IVUS Antithrombotic: aspirin, clopidogel, and heparin Stenting strategy TAKE HOME MESSAGES Percutaneous coronary intervention (PCI) for left main trifurcation lesion is challenging. No one-size-fits-all strategy is available The choice of treatment strategy is depended on the discrepancy between vessel size, extent of calcification, angle between vessels, etc. To be familial with various PCI techniques, including provisional one stent and two-stent technique as well as the way to protection side branch, is the key to successful PCI for leI main trifurcation lesion

Double Debulking for LM True Bifurcation Lesion

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING Double Debulking for LM True Bifurcation Lesion Author: Yoshihisa Kinoshita, MD, Toyohashi Heart Center, Japan CONCLUSION Although short DAPT theory becomes widespread recently, we have to keep DAPT after stenting at least 3 to 6 months at least. Especially, it is difficult to stop DAPT within 1 month for the patient who have stent in LM bifurcation lesion. However, there are some patients who cannot continue enough DAPT because of their underlying condition. Aggressive debulking without stenting occasionally brings a favorable result for such patients.

Get Clarity with OCT for LM and Bifurcation PCI Case 1 Complex Bifurcation

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain ABBOTT SYMPOSIUM Get Clarity with OCT for LM and Bifurcation PCI Case 1 Complex Bifurcation Author: Tom Johnson, MD, Bristol Heart Institute, UK CASE SUMMARY Stent failure MANDATES intra-vascular imaging Stent under-expansion common driver but multifactorial Image guidance for plaque modification is critical

Megatron Synergy – The new addition to the synergy family

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BOSTON SYMPOSIUM Megatron Synergy. The new addition to the synergy family Author: Yiannis Chatzizisis, MD, PhD, University of Nebraska Medical Center, USA ONGOING/ FUTURE WORK Testing the performance of Megatron with 2-stent techniques in a larger cohort of LM bifurcations Head-to-head comparison of Megatron with other second generation DES Testing the performance of new purpose-built stents dedicated to other segments of the coronary tree e.g, distal segments A large, virtual clinical trial to show improved morphologic and biomechanical endpoints (which serve as surrogates of clinical outcomes) with purpose-built stents.