LM Bifurcation Distal PCI – If You Use Crush Technique It Should Be DK Crush

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CONSENSUS SESSION - VOTING LM Bifurcation Distal PCI - If You Use Crush Technique It Should Be DK Crush Author: Imad Sheiban, MD, PhD, Pederzoli Hospital -Pechiera D/G (Verona), Italy Left main Bifurcation : It is different , not MV- SB but 2 MVs .. Optimal treatment should be provided for both branches TAKE HOME MESSAGES: For complex LM BLs, 2-stent technique especially DK crush is associated with Excellent clinical outcome Serial Randomized Clinical Trials were able to demonstrate that in complex bifurcations , DK Crush is associated with better clinical outcome as compared to other techniques and should be be considered a the gold standard when crush technique is used

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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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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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NOBLE Five Year Follow Up

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION NOBLE Five Year Follow Up Author: Niels Ramsing Holm, MD, Aarhus University Hospital, Denmark BACKGROUND Initial NOBLE report (LANCET 2016) indicated that PCI was inferior to CABG for MACCE Mortality was similar No difference in stroke Higher rates of spontaneous MI and revascularization after PCI CONCLUSIONS The NOBLE trial is conclusive: PCI was inferior to CABG in treatment of LMCA stenosis at 5 years for the primary endpoint of MACCE  Mortality was similar for PCI and CABG Difference in MACCE driven by higher rates of non-procedural myocardial infarctions and repeat revascularization after PCI SYNTAX score <23 did not identify a subgroup with more balanced outcome CABG had longer index admissions, more reOP, more blood transfusions Heart Team conference AND thorough balanced discussion with the patient

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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

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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.

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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.

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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.

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