MEDTRONIC - Sponsored Symposium: Advancing Left Main PCI – Evidence, technique, and stent considerations.
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Ideal LM Author: Rober Jan Van Geuns, MD, PhD, Radboudumc, The Netherlands CONCLUSIONS After 2 years, in patients undergoing LM-PCI, a Bioabsorbable Polymer Everolimus-Eluting Platinum Chromium stent (Synergy) followed by 4 months DAPT was non-inferior to a Permanent Polymer Everolimus- Eluting Cobalt Chromium stent (Xience) followed by 12 months DAPT with respect to the composite end point of death from any cause or MI or ischemia-driven target vessel revascularization. No difference in ischemic events up to 24 months • No difference in definite/probable stent thrombosis • No stent thrombosis in either group from 4 to 12 months (Synergy off DAPT) Excess BARC 3 or 5 bleeding in short DAPT group but... •4/11 were on OAC/NOAC (2 on triple Rx) and 7/11 were off DAPT • Trial not powered for bleeding events
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.
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.
European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 1 Learnings From the Bench and a Thrombogenicity Model Author: Nicolas Foin, MSc, PhD, National Heart Research Institute Singapore; Philips Healthcare, Belgium LEARNINGS FROM THE BENCH Bench models allow to study questions in controlled and reproducible experimental environments Make use tools such as Micro-CT, Radial & Longitudinal Strength tes;ng, 3D printing, Perfusion test, Histology, SEM Microscopy. LIMITATIONS It can only provide a partial model to investigate a question and cannot mimic the entire tissue /plaque characteristics and in-vivo biological response. Results can not always be transposed directly to in-vivo situations and should be interpreted with caution. Bench models complement, but do not replace clinical/imaging studies SUMMARY Stent underexpansion and stent malapposition distances affect flow disturbances and shear rate in a dose-dependent relation. Severe malapposition (ISA distance > 300 um) create higher shear rate with persitent malapposition + uncovered strut at follow-up. In-vitro experiments with perfused blood suggest that large malapposed stent segment create potential sites for platelet adhesion and clot development. Stent optimisation (expansion and apposition) with appropriate sizing, post-dilatation and imaging can improve local hemodynamic environment and reduce area of high shear disturbance.
A case of huge coronary perforation during insertion of a long stent in severe calcified bifurcation lesion Author: Yoshinobu Murasato, MD, PhD, Kyushu Medical Center, Japan Take home messages: • A long stent insertion in the calcified bifurcation lesion led to stack of the stent and S-figure flection which resulted in huge coronary perforation. • The situation that 1/3 of the stent remained in the guiding catheter might induce strong push-ability to make S-figure flection in the coronary artery. • When we feel hard resistance during insertion of a long stent, we should consider another option as the following earlier. Biplane fluoroscopy for detailed observation of the stent stack Buddy wire to change the wire bias Guide extension catheter to enhance back-up force and prevent the stent flection inside the coronary artery.
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
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