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

Introduction: Are bifurcation stenting simulations needed?

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS Introduction: Are bifurcation stenting simulations needed? Author: Habib Samady, MD, FACC, Emory University Hospital, USA ARE BIFURCATION STENTING SIMULATIONS NEEDED? - YES Outcomes of bifurcation PCI are not optimal Bench Micro CT studies can inform bifurcation stenting strategies Macro or vessel level hemodynamics require 3 D vessel and stent reconstruction Micro or strut level hemodynamics require complex and time consuming computational techniques for evaluating the interaction of plaque prolapse, strut morphology and perhaps stent healing Prospective studies (SHEART STENT and ISR FLOW) are underway to investigate the prognostic value of hemodynamics as they relate to vascular healing of in angulated and bifurcation PCI.

A randomized trial evaluating on line three dimensional of guided PCI vs angiography guided PCI in bifurcation lesions OPTIMUM STUDY

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CORONARY BIFURCATION IMAGING A randomized trial evaluating on line three dimensional of guided pci vs angiography guided pci in bifurcation lesions: optium study Author: Yoshinobu Onuma, MD, PhD, Erasmus Medical Center, The Netherlands BACKGROUND In bifurcation PCI, re-crossing the distal cell with a wire after main vessel stenting is important to avoid creating a de novo metal carina1. Those protruded/malapposed struts result in lower tissue strut coverage of the side branch ostium and more overhanging metal into the main branch after implantation of the stent. Angiography guided PCI is limited in recognizing the recrossing position, while intracoronary imaging during PCI has a potential to visualize the recrossing point and to optimize the acute results.  The feasibility of off-line 3-dimensional optical frequency domain imaging (OFDI) in bifurcation and its potential benefits were demonstrated in retrospective studies. However, the feasibility and efficacy of on-line 3D OFDI guided PCI in bifurcation lesion has not yet been fully investigated. OBJECTIVE To determine whether bifurcation PCI guided by on-line 3D- OFDI is superior to bifurcation PCI with angiographic guidance in terms of incomplete stent apposition (ISA) in bifurcation segment. CONCLUSION In the randomized trial of bifurcation PCI, 3D-OFDI guidance was superior to angio-guidance in acute incomplete strut apposition (creation of metal carina) of bifurcation segment (3D-OFDI 19.5±15.8% vs. angio: 27.5%±14.2%, p=0.008). Excellent feasibility of online 3D-OFDI was demonstrated (98%). After mandatory POT, the first wiring position was not optimal in 45% of cases, requiring 2nd attempt to redirect the wire into the optimal cell when 3D-OFDI guidance was used. On-line 3D OFDI images help operator to undergo rewiring to the optimal cell, resulting in a lower rate of malapposition compared with angiography guided PCI.

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.

Balloons and stent sizing for bifurcation PCI Role of Intra-coronary Imaging

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CORONARY BIFURCATION IMAGING Balloons and stent sizing for bifurcation PCI Role of Intra-coronary Imaging Author: Yoshinobu Murasato, MD, PhD, Kyushu Medical Center, Japan TAKE HOME MESSAGES Device sizing (general): EEL-based reference diameter measurement is firstly recommended. In case of invisible EEL, lumen-based measurement is also available. For the optimal stent landing zone, it is important to avoid dissection, > 50% plaque burden, and lipid pool. Device sizing: bifurcation lesion POT and KBI balloon should be selected according to vascular branching law. In the bifurcation lesion, Finet’s law is applicable for imaging-guide reference diameter measurement, not for angio-based one. Stent should be selected considering maximal expansion capacity. Minimum expansion index considering vascular branching and tapering is more physiological to select post-dilation site and appropriate balloon.

Why I prefer IVUS in bifurcation guidance

European Bifurcation Club 2014, EBC 2014 - Bordeaux, France LIVE BIFURCATION STENTING GUIDANCE: OCT, IVUS, FFR & ANGIO Why I prefer IVUS in bifurca3on guidance Author: Masahiro Yamawaki, MD, PhD, Saiseikai Yokohama City Eastern Hospital, Japan SUMMARY The mechanism of luminal widening by FKI was stretching vessel wall. FKI corrected carina/plaque-shift in about 30%. Plaque shift dominantly occurred(50%) The vessel anatomy assessed by IVUS before intervention /FKI was predictable for plaque/ carina shift, and associated with residual SB ostium stenosis despite FKI. CONCLUSION Why I prefer IVUS in bifurcation guidance” Because we can check optimal result after stenting by IVUS. In addition, IVUS before- and during PCI helps us to .... know precise anatomy, and predict SB compromise as well as luminal widening after FKI. make decision of final strategy of bifurcation-PCI make our procedure logical and predictable !

OCT in Stent Failure

European Bifurcation Club 2014, EBC 2014 - Bordeaux, France LIVE BIFURCATION STENTING GUIDANCE: OCT, IVUS, FFR & ANGIO OCT in assessment of stent failure at the bifurcation level Author: Tom Adriaenssens, MD, PhD, University Hospitals Leuven, Belgium CONCLUSION Bifurcation PCI treated segments do not constitute a majority of cases with ST in the Prestige OCT registry (16/230) Inclusion bias possible (more severe cases did not make it to the cath lab/did not undergo OCT during PCI) Problems of thrombus around floating struts and UC/MA/overlap in remote areas but related to bifurcation PCI technique predominant

Insights from the Thoraxcenter DES

European Bifurcation Club 2005, EBC 2005 - Bordeaux, France DEBATE - Which approach for LM stenting with DES? Which approach for LM stenting with DES? Insights from the Thoraxcenter DES Author: Angela Hoye, MD, Castle Hill Hospital, UK METHODOLOGY As a policy, all elective patients presenting with significant (>50% by visual estimation) LM disease are evaluated by both interventional cardiologists and cardiac surgeons and the decision to opt for PCI or surgery is reached by consensus The interventional strategy was left to the operator’s discretion All patients were maintained on lifelong aspirin, with clopidogrel for 1 month in those treated with BMS, and 6 months for those treated with DES MACE: death CONCLUSION Compared with historical data of bare metal stents, the adverse event rate is lower following DES implantation for LMS disease The majority of adverse events occur within 1 year The long-term angiographic outcome of the main vessel was not significantly affected whether or not the side branch was stented The long-term angiographic outcome of non-stented side branches was similar to that of stented side branches Both single stent and 2-stent strategies appear to be reasonable options for the therapy of distal LMS disease There is unlikely to be a single strategy that is broadly applicable to all anatomies and lesion subtypes. Further research with randomised studies is needed to evaluate outcomes with respect to the strategy used for differing bifurcation lesions