Impella and LM Stenting with PS and POT: Keep it Simple

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASES SESSIONS - TIPS & TRICKS Impella and LM Stenting with PS and POT: Keep it Simple Author: Johan Bennett, MD, PhD, University Hospitals Leuven, The Netherlands CLINICAL CASE 64 year old male Diabetes Mellitus, ex-smoker Prostrate cancer with bone mets (stable on hormone therapy) Presented with ACS and pulmonary oedema SUMMARY Protected High risk PCI of LM bifurcation Impella CP supported Ventriculo-arterial uncoupling Provisional LM stenting Intracoronary imaging to ensure optimal result

Short LM – Problem of ostial coverage

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain COMPLICATION CASES Devil wears Prada: LM stenting, problem of ostium coverage Author: Himanshu Gupta, MD, DM, PGI Chandigarh, India CLINICAL PROFILE 50 Years Male HTN, No DM, Former Smoker 1 episode of Syncope 10 days back ECG – Normal with no baseline ST changes Evaluated at OSH and found to have CAD LVEF- Normal LV function with no baseline RWMA or valve disease PROBLEM After FKB the LAD wire position was lost as the balloon got stuck on the wire LAD rewired with another wire Position of the fresh LAD wire in doubt?? LCX wire is good–Maybe, we have done a FKB already LEARNING POINTS Short LM and abnormal take off can cause problems FKB not mandatory in provisional SB strategy If u KISS – It should be good and safe Rewiring always after POT – But be careful Use dual lumen catheter to wire SB if in doubt Never do POT on SB wire Use Guide extension to prevent LSD Angiographic follow up if possible

DK Crush vs tap. In vitro comparison of thrombogenicity and flow

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS DK Crush vs tap. In vitro comparison of thrombogenicity and flow Author: Valeria Paradise, MD, Maasstad Hospital, Rotterdam, The Netherlands OBJECTIVE The purpose of the present study was to compare DKC vs TAP technique to evaluate their different effects in terms of strut apposition and thrombus formation in in-vitro models using OCT and computational flow reconstruction. METHODS N= 12 stents in total (Synergy n=6 and Ul(master=6) Bifurcation y-shaped model Stent with same platform were deployed using TAP or DKC technique Final POT was performed for all the experiments OCT pullback was performed from MV and SB before and after POT A peristaltic pump was used to perfuse the porcine blood through the silicone model at a flow rate of 200ml/min for 4 minutes Thrombus area was calculated from OCT pullback after perfusion CONCLUSION No difference in terms of stent struts apposition Similar acute thrombus formation POT significantly reduces EI Even when performed in silicon model, these procedures are associated with stent malapposition

Risk of Re-POT: Effect of proximal balloon edge dilation technique for opening side branch ostium in re proximal optimzing sequence

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS Risk of Re-POT: Effect of proximal balloon edge dilation technique for opening side branch ostium in re proximal optimzing sequence Author: Teruyoshi Kume, MD, Kawasaki Medical School Hospital, Japan CONCLUSION Re-POT sequence is excellent PCI procedure for bifurcation lesions. In re-POT sequence, PBED technique with short balloon for SB inflation might minimize the worsening of jailing ratio at SB ostium during second POT procedure.

Flow disturbance due to incomplete stent apposition

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS Flow disturbance due to incomplete stent apposition Author: Kiyotaka Iwasaki, PhD, Waseda University, Japan BACKGROUNDS In left main bifurcation, difference between LMT (proximal) and LAD (distal) diameters is lager compared with that in other bifurcation. Stenting without POT would induce incomplete stent apposition at proximal bifurcation side. KBT is recommended to open overlaying stent of side branch ostium especially in LM Bifurcation, because the overlaying jailed stent will potentially occupy larger at LCx and become a source for future thrombus formation, neointimal formation, and late narrowing. Although stent-size selection based on distal diameter is recommended, there is a dilemma that currently available stents have smaller expansion capability when stent-size is chosen based on distal stent-landing diameters in LAD. SUMMARY AND TAKE HOME MESSAGES POT and KBT are mandatory to reduce incomplete stent apposition. Otherwise, abnormal slow flow regions were induced at left main trunk and/or behind jailed stent crowns during the cardiac cycle, which would be a potential cause of thrombus formation and may necessitate life-long DAPT.  Stent-diameter selection based on the proximal- vessel diameter is feasible to preserve stent platform design at LMT and bifurcated region, and to reduce jailed stent crowns at LCx ostium. Three-times kissing balloon inflation is feasible for reducing jailed stent crowns.

Call for the Participation in Bifurcation DEB Trials

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BIFURCATION AND DRUG ELUTING BALLOONS - VOTING Call for the Participation Bifurcation DEB Trials Author: Sudhir Rathore, MD, Frimley Health NHS Foundation Trust, UK Provisional Group: Main vessel DES + KBI+POT vs. MV DES + DEB to SB+ POT: Late Loss/ Binary restenosis at SB/MB/ MACE 2 stent strategy: (SB> 70%/ 10 mm ): 2 stent+ KBI vs. MV DES + DEB to SB + KBI Call for meeting to discuss the results of polling and further discussion.

DCB in the treatment of bifurcations: Scenarios for future studies

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BIFURCATION AND DRUG ELUTING BALLOONS - VOTING DCB in the treatment of bifurcations: Scenarios for future studies Author: Juan Luis Gutierrez Chico, MD, Cardiac Care - Cardiovascular Heart Centre Marbella, Spain 4 POSSIBLE SCENARIOS 1st scenario: NORDIC-III-like 2nd scenario: BBC-ONE-like 3rd scenario: rePOT 4th scenario: rePOT-DOT

Existing data on drug coated balloons and coronary bifurcation treatment

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BIFURCATION AND DRUG ELUTING BALLOONS - VOTING Existing data on drug coated balloons and coronary bifurcation treatment Author: Mario Araya, MD, Clinica Alemana De Santiago/ Thorax National Institute, Chile 4 STRATEGIES TESTED DCB with BMS DCB with DES DCB-only strategy DCB in bifurcaAon restenosis WHERE DO WE STAND Trials of DCB in bifurcaAon treatment use different protocols and devices, in small trials. No POT, low kissing. We need more data. Only paclitaxel-coated balloon have been reported. In general, the use of pDCB appears to be effective and safe in SB. The use of pDCB + BMS is inferior to conventional DES treatment The use of pDCB + DES (Everolimus) show excellent results in small registries . Only-DCB strategy is feasible and safe. In Restenosis of bifurcation, including LM, DCB tx show promising results compare to DES

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.

Optimal Provisional Coronary Bifurcation Stenting

European Bifurcation Club 2014, EBC 2014 - Bordeaux, France ADVANCEMENTS IN BENCH TESTING AND COMPUTER MODELING Optimal provisional coronary bifurcation stenting: Final kissing balloon dilatation or not ? Author: Gerard Finet, MD, PhD, Hospices Civils de Lyon, France OBJECTIVES Quantify the mechanical effects of the POT Quantify the differences between: FKB approach (with its modified protocols) after POT approach with no FKB but consecutive POT with SB balloon inflation (re-POT) CONCLUSION Our preliminary results with 25 fractal bifurcation models with Promus Premier® (Boston) : quantitatively validated the mechanical effects of POT showed by comparison with : FKB alone and POT + FKB with symmetric or asymmetric balloon inflaOon pressure thatwithre-POT with SB dilation provides the best mechanical results and is the simplest technique in 1-stent bifurcation strategy. SBO almost free of strut (4.9%) a very low rate of global strut malapposition (2.6%) an almost perfect morphology of the carena and the wall facing the SB ostium a maintained circular cross-sectional area of the MoV (relative elliptic ratio : 1.0) the almost perfect respect of the linear law of coronary artery bifurcation geometry (0.66) We are completing these preliminary results with 25 other fractal bifurcation bench models with Ul#master® stent (Terumo) A total of 50 experimentations in fractal bifurcation bench models.