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

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.

What are the Best Imaging Criteria for Adequate Stent Expansion and Apposition in Bifurcation Lesion

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CORONARY BIFURCATION IMAGING What are the Best Imaging Criteria for Adequate Stent Expansion and Apposition in Bifurcation Lesion Author: Nicolas Amabile, MD, PhD, Institut Mutualiste Montsouris, Paris, France CONCLUSION Best imaging criteria for bifurcation PCI quality assessment are not completely established. Although consensus criteria exist for non bifurcated lesions, they might not be applicable “as they are” to bifurcations. Malapposition criteria can be applied for MV and MB. Special alention must be given in the future to redefine our objectives for adequate stent expansion.

Trend of Bifurcation PCI from COBIS I to COBIS III

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 2 Trend of Bifurcation PCI from COBIS I to COBIS III Author: Joon Hyung Doh, MD, PhD, Inje University Ilsan Paik Hospital, Goyang, Korea  & Ki Hong Choi, MD, Samsung Medical Center, Seoul, Korea CONTEXT Trend of Bifurcation PCI in Korea using COBIS I, COBIS II, and COBIS III Registries Comparison of Inclusion Criteria and Baseline Characteristics Changes of Treatment Strategies Comparison of Follow-up Clinical Outcomes SUMMARY From COBIS I to COBIS III, left main bifurcation PCI is increasing. 1-stent strategy is still the most preferred technique (81.5% in COBIS III), even in LM bifurcation PCI. Among various 2-stenting techniques, the ‘crush technique’ is the most commonly used in Korea. The use of IVUS and trans-radial intervention are also on the rise in patients under went PCI with bifurcation lesion. Although proportion of FKB was reduced in COBIS III (compared with COBIS II), th e concept of POT have been newly developed and widely used. From COBIS I to COBIS III, the incidence of MACE (cardiac death, MI, and TLR) tren d toward to decrease in real world bifurcation PCI.

From QFR to OFR: Intracoronary OCT derived FFR for Assessment of Stenosis Severity

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 2 From QFR to OFR: Intracoronary OCT-derived FFR for assessment of stenosis severity Author: Shengxian Tu, MD, PhD, Shanghai Jiao Tong University, China Limitations of angiography-based FFR Angiographic image overlap and significant foreshortening Post-PCI optimization: stent mal-apposition/under-expansion OFR Analysis Steps Automatic OCT lumen contour delineation and 3D reconstruction Automatic reconstruction of cut- planes at the side branches ostia Compute OFR using the QFR algorithm SUMMARY OFR (OCT-based FFR) provides lesion morphology and physiological assessment in a single OCT pullback. Compared with FFR, OFR showed good diagnostic accuracy, excellent reproducibility and short analysis time. OFR had substantially better diagnostic accuracy than OCT-MLA. OFR is promising for use in the cath lab for PCI optimization.

Stop DAPT2 High Bleeding Risk sub analysis

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 1 STOPDAPT2 HBR Bifurcation. 1 Year outcomes from a Randomized Trial of Clopidogrel Monotherapy VS DAPT Beginning 1 Month After PCI in Patients at High Bleeding Risk Author: Hirotoshi Watanabe, MD, Kyoto University Hospital, Japan LIMITATIONS Post-hoc, and underpowered analysis. Precise ARC-HBR could not be applied.  Very few patients participated in this study with 2-stents for bifurcation. Japanese patients are known to have lower ischemic risk and higher bleeding risk compared with US/European population CONCLUSION The effects of 1-month DAPT versus 12-month DAPT on the primary and major secondary endpoints were consistent in HBR patients and any bifurcation strategy without any significant interactions. One-month DAPT was associated with significant reduction of major bleeding without any increase of cardiovascular events in HBR patients, and the absolute magnitude of bleeding events with 1-month DAPT was numerically greater in HBR patients than in non-HBR patients, although the analysis was underpowered and needed confirmation in future studies. In this study very few patients with complex PCI for bifurcation participated, but there was no sign 1-month DAPT significantly increased the coronary-related events

Clinical Case

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Clinical Case Author: Julien Adjedj, MD, Institut Arnault Tzanck, France 68 YEAR OLD MALE PATIENT HIV Previous inferior MI in 2006 Left main equivalent PCI in 2006 Cypher 3.5 x 18 mm Dyspnea NYHA II LVEF 40% inferior akinesia

Protective Strategy for Side Branch in Complex Bifurcation Lesions During PCI

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain COMPLICATION CASES Protective Strategy for Side Branch in Complex Bifurcation Lesions During PCI Author: Man Wang, MD, Fuwai Hospital, China SUMMARY Provisional stenting strategy is preferred in non-left main BIF Jailed balloon technique is effective for keeping side branch open with high success rate of rewiring Easy withdrawal of jailed wire and balloon in SB Rewiring and final KBI is not necessary when SB TIMI flow is 3

A case of IVUS to LM Bifurcation lesion with IABP support

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain TIPS AND TRICKS IN BIFURCATION PCI - THE SYNERGY BETWEEN EBC AND ASIA Author: GUO Suxia, MD, Dongguan People's Hospital, China CASE PRESENTATION PATIENT DEMOGRAPHICS:  - Age: 48 yrs.  - Gender: Male RISK FACTORS:   -  2-DM  - Smoking history CLINICAL PRESENTATION:  - Exertional chest pain for 2 years.    - Echo: LVEF 47% PAST MEDICAL HISTORY:  - CAG in other Hospital before one week STRATEGY LM/LAD/LCX bifurcation (1,1,1):  2 stents Middle of LCX CTO: PCI Intro-coronary imaging guidance: IVUS