Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry Author: Kazushige Kadota, MD, PhD, Kurashiki Central Hospital, Japan SUMMARY 1 The Long-term outcomes ager stent implantation for unprotected LMCA lesions were not determined by the bifurcation lesion types, but were related to the 2- stent strategy. Also, the difference in the rates of TLR and ST between 1-stent and 2-stent strategies were observed within 1 year. SUMMARY 2 Drug-eluting stent implantation ager rotational atherectomy was a safe and feasible strategy for complex bifurcation lesions. In this strategy, the 2-stent approach was associated with markedly worse 5-year clinical outcomes than the 1-stent approach. The events rate within 1 year were significantly higher for all outcomes in the 2-stent strategy group than in the 1-stent strategy group. CONCLUSION The AOI-LMCA registry confirmed that a simple stenting strategy could be recommended for treating leg main bifurcation lesions in real world practice. Meticulous care should be paid within 1 year after using a complex stenting strategy.

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Coronary CT Guided Left Main Bifurcation PCI

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Coronary CT Guided Left Main Bifurcation PCI Author: Masaaki Okutsu, MD, New Tokyo Hospital, Chiba, Japan Introduction Current consensus of LMT bifurcation PCI recommends single stent strategy. However, LCX ostium has sometimes severe stenosis or occlusion after crossover stenting unexpectedly. There are some factors that affect to jailed LCX ostium. – MB plaque, SB plaque, low angle, and ...Calcification is one of them. Objective To investigate the relationship between calcium thickness at LMT bifurcation and LCX ostium deterioration after LMT-LAD crossover single stenting. Conclusion Coronary CT might be able to measure calcium thickness. Calcium thickness of ostial LAD might affect LCX ostium stenosis deterioration after crossover stenting from LMT to LAD.

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Ideal LM

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

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Efficiency of Drug Coated Balloon after Directional Coronary Artherectomy for Coronary Bifurcation Lesions

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Efficiancy of Drug Coated Balloon after Directional Coronary Artherectomy for Coronary Bifurcation Lesions - DCA/DCB Registry -As an Option of Stent-less PCI Strategy for Bifurcation Lesions- Author: Shunsuke Kitani, MD, Tokeidai Memorial Hospital, Japan BACKGROUND The optimal strategy for bifurcation lesions still remains controversial even in DES era. DCA-alone had high restenosis rate (20-50%) and TLR rate (15-37%) due to excessive intimal hyperplasia after DCA. Combined DCA and DES for bifurcation lesions reduced restenosis rates (Maiin V 1.1%, SB 3.4%). OBJECTIVES To evaluate the efficacy and safety of DCA/DCB forbifurcation lesions. CONCLUSION DCA/DCB for bifurcation lesions provided good clinical outcomes, minimizing side branch damage. DCA/DCB can be one of the good options as stent-less PCI strategy for bifurcation lesions, especially LMT.

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EXCEL 5 Years and SYNTAXES 10 years

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION EXCEL 5 Years and SYNTAXES 10 years Author: Patrick Serruys, MD, PhD, Imperial College London, UK TAKE HOME MESSAGES (10 years) First Randomized Trial to report 10-Year Survival after CABG or PCI with drug-eluting stents in patients with de novo Three-Vessel and Left Main Disease Completeness of follow-up at 10-Year = 94% (well-balanced across CABG and PCI) No survival difference in between CABG and PCI at 10 years in overall cohort Increased survival with CABG vs PCI in Three-Vessel disease Comparable survival with CABG vs PCI in Left Main disease Non-compliance to the SS II treatment recommendation resulted in a numerically higher risk of all-cause death at 10 years. TAKE HOME MESSAGES (5 years) Four Randomized Trials to report 5-Year Survival after CABG or PCI with drug-eluting stents in patients with de novo Left Main Disease. No survival difference in between CABG and PCI at 5 years in the left main disease from a pooled patient level meta analysis. In the EXCEL trial, Non-compliance to the SS II treatment recommendation (CABG) resulted in a significantly higher risk of all-cause death when randomised to PCI. Compliance to the SS II treatment recommendation (Equipoise) resulted in a non- significant difference in all-cause mortality when randomised to either CABG or PCI.

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Long Term Results after PCI of Unprotected Distal Left Main Stenosis

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Long Term Results after PCI of Unprotected Distal Left Main Stenosis Author: Miroslaw Ferenc, MD, University Heart Center Freiburg, Germany CONCLUSIONS Compared with single stenting, double stenting was associated with a significantly higher long-term risk of MACE. Higher incidence of TLR, whereas the risk of death, MI, or stent thrombosis was similar After critical first year the MACE during long term follow-up similar between single and double stenting Randomized study EBC-Main ongoing (single vs double)

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Differential Prognostic Impact of Treatment Strategies for LM Versus Non LM Bifurcation Lesion.

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Differential Prognostic Impact of Treatment Strategies for LM Versus Non LM Bifurcation Lesion. Lessons from the COBIS Registries Author: Young Bin Song, MD, PhD, Samsung Medical Center, Korea Stent Technique (1-Stent vs. 2-Stent) The 1-stent strategy, if possible, should initially be considered the preferred approach for the tr eatment of coronary bifurcation lesions, especially LM bifurcation lesions. Clinical Outcomes Between LM VS Non-LM Patients with LM bifurcation showed significantly higher risks of target lesion failure, cardiac d eath or myocardial infarction, and target lesion revascularization compared to those with non-L M bifurcation. CONCLUSION & SUMMARY Patients treated with PCI for an LM bifurcation lesion had poorer outcomes than those with a non-LM bifurcation lesion in the era of second-generation DES. In the treatment of LM bifurcation, the 2-stent strategy was associated with a higher risk of T LF than the 1-stent strategy, mainly driven by higher risk of TLR; however, incidence of cardiac death or MI was not different between the strategies, unlike previous results from the COBIS II registry. In the treatment of a non-LM bifurcation, there were no significant differences in TLF, cardiac death or MI, and TLR between the 1-stent and 2-stent strategy groups.

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Nano Crush in Left Main

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain NEWS 3 Nano Crush in Left Main Author: Gianluca Rigatelli, MD, PhD, Rovigo General Hospital, Italy NANO CRUSH FACTS 2014 : conceiving the technique and first application of the technique in LM and non-LM patients 2015 : application in shock patients 2017 : publication first preliminary series in Cardiovasc Revasc Med 2018 : publication of bench and computational fluid dynamic study in Cathet Cardiovasc Interv 2019 : Nano-Crush in Left main and cardiogenic shock in Cardiovasc Revasc Med 2019 : comparison between Nano-Crush and Culotte in Left main in Int J Cardiovasc Imag CONCLUSION Nano-crush stenting in Left Main showed improved long- term outcomes with low TVF, low mortality and 0% thrombosis compared to other double stent techniques Nano-crush stenting in Left Main provided easy and fast revascularization, low X-ray exposure and low contrast dose Nano-crush stenting can be an alternative to DK-crush in complex Left Main bifurcation disease

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Ivus guided LAD CTO/LM – bifurcation stenting

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Ivus guided lad cto lm bifurcation stenting Author: Dr Joby K Thomas, MD, DM, Caritas Hospital Kerala, India SUMMARY Patient underwent CABG and mitral valve repair in 2014 at a different hospital Had effort angina which revealed occluded LIMA and both SVGs(2017) They attempted PTCA , did RCA and ‘ramus ‘ stenting LAD was ostial CTO , which they could not succeed in doing Patient still has angina Check angio showed patent stents in RCA and ‘ramus’ That converted a 0,1,1 LM distal bifurcation to 0,1,0 But LAD ostial CTO with no stump

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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

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