Left Main madrid 2013, Dr Antonio Colombo

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Presentación del Dr Antonio Colombo sobre el tratamiento percutáneo del tronco común.

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  • Doe this make any difference.
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  • Left Main madrid 2013, Dr Antonio Colombo

    1. 1. Antonio Colombo Centro Cuore Columbus and S. Raffaele Scientific Institute, Milan, Italy Madrid: 2-4 October 2013 Speaker – 15’ Complex Coronary Interventions – PART 2 Round Table 1 –Left Main Coronary Treatment
    2. 2. A case for surgery even in the era of Drug Eluting Stent
    3. 3. ESC guidelines 2010 – CABG vs. PCI • Left main (isolated or 1VD ,ostium/shaft) - CABG = IA, PCI = IIa B • Left main (isolated or 1VD, distal bifurcation) - CABG = IA, PCI = IIb B • Left main + 2VD or 3VD,SYNTAX score < 32 - CABG = IA, PCI = IIb B • Left main + 2VD or 3VD,SYNTAX score 33 - CABG = IA, PCI = III B * I/IIb/III = recommendation class, A/B = level of evidence
    4. 4. Guidelines summary • CABG gold standard but PCI good option in ostial/shaft disease or when SYNTAX ≤ 22 and risk of surgical complications is relatively high • PCI also acceptable in high surgical risk patients with distal LM disease or when SYNTAX ≤ 32 • PCI should not be performed in patients who can undergo CABG and have unfavourable anatomy (SYNTAX > 33)
    5. 5. SYNTAX 0-22 SYNTAX 23-32 SYNTAX ≥ 33 SYNTAX trial MACE subanalysis – LMS and SYNTAX score CABG PCI
    6. 6. DELTA substudy – ostial/midshaft vs. distal LMS Difference in MACE driven by TVR with no difference in all-cause death or composite of all-cause death and MI Distal Ostial /midshaft
    7. 7. 5 yrs. results in the LM COMPARE trial, SJ Park et al. JACC Inter
    8. 8. PCI and CABG do not work by intention to treat The most important issue is long term results In PCI success is “WRONGLY” defined as successful stent placement Optimal: IVUS confirmed stent placement, should be (in my view) the gold standard
    9. 9. 591 (85.8%) patients treated with DES for ULM between April 2002 and December 2010 349 (55%) patients treated using 1-stent 266 (45%) patients treated using 2-stent Exclusion criteria Acute MI, ISR, dissection and CABG 75 (28.2%) Mini-crush or T-stenting 52 (19.5%) Culotte stenting 32 (12.0%) SKS or V-stenting 51 (19.2%) Crush stenting 29 (10.9%) Provisional T, TAP-stenting 325 (93.1%) LM-LAD stenting 24 (6.9%) LM-LCx stenting 494 patients (84.0%) with angiographic follow-up 84 ostial/ body ULM lesion 14 ULM treated with 3-stent 689 patients treated with DES for ULM between April 2002 and December 2010 In Milan and New-Tokyo The overall cardiac-death, MI and MACE during the follow-up (median 24 months) occurred in 4 (5.1±2.5%), 2 (2.9±2.0%) and 31 (38.2±5.4%) patients respectively. Repeat-TLR occurred in 28 (34.7±5.3%) patients.
    10. 10. Main findings • The main issue in LM disease is not LM disease but associated 3V disease • In LM bifurcation lesions restenosis of the LCx is frequent but does not impact on mortality (the obsession of LCx restenosis)
    11. 11. Index procedure Baseline September 2004
    12. 12. Left Main restenosis September 2004 Final Result Cypher Mini-Crush
    13. 13. Routine follow-up, pt. asymtomatic Febr 2005 5- Month FU No Treatment
    14. 14. Left Main restenosis Febr 2005 5- Month FU No Treatment
    15. 15. 2nd FU: pt asymptomatic June 2005 8- Month After LM stent
    16. 16. June 2005 8- Month After LM stent
    17. 17. LCx restenosis June 2005 8- Month After Cypher V-Stenting Final Result
    18. 18. LCx restenosis March 2006 17- Month After first PCI No Treatment 9- Month After Second PCI
    19. 19. LCx restenosis November 2008 Baseline 41- Month After Second PCI
    20. 20. LCx restenosis November 2008 Endeavor Resolute Culotte 41- Month After Second PCI
    21. 21. LCx restenosis November 2008 Final Result 41- Month After Second PCI
    22. 22. Baseline Angiographic and Procedural Characteristics of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy (I) Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value LM+ 3VD 168 (41.4) 90 (36.9) 78 (48.1) 0.03 High SYNTAX score 144 (39.2) 88 (38.6) 56 (40.3) 0.83 Stenosis of Left circumflex >75% 176 (37.4) 71 (25.4) 105 (54.1) 0.001 Stenosis Length of Left circumflex >10mm 93 (22.1) 38 (15.3) 55 (32.2) 0.003 True-Bifurcation Medina 111,101,011 291 (61.4) 134 (47.9) 157 (80.9) 0.001 ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound
    23. 23. Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value IABP 66 (14.5) 27 (10.3) 39 (20.4) 0.003 IVUS 230 (48.5) 147 (52.5) 83 (42.8) 0.04 Rotational Atherectomy 34 (7.5) 23 (8.4) 11 (6.0) 0.37 Total Stent Length 25.97±12.05 22.47±7.19 30.85±15.35 0.001 Baseline Angiographic and Procedural Characteristics of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy (II) ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound
    24. 24. Outcome at 3 Years of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value Angiographic follow-up 405(89.8) 234 (89.3) 171 (90.5) 0.48 All-death 38 (8.5) 24 (9.0) 14 (7.7) 0.74 Cardiac-death 21 (4.5) 14 (5.1) 7 (3.6) 0.37 Non Cardiac death 17 (3.6) 10 (3.6) 7 (3.6) 0.49 In-stent restenosis 85 (17.9) 35 (12.5) 50 (25.8) 0.01 In-stent restenosis at the ostial LCX 41 (8.6%) 14 (5.0%) 27 (13.9%) 0.001 Myocardial Infarction 6 (1.3) 3 (1.1) 3 (1.6) 0.10 ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound
    25. 25. IVUS evaluation mandatory every time 2 stents are implanted: If IVUS cath does not cross the stent perform a better postdilatation
    26. 26. Before After After appropriate sizing
    27. 27. Final
    28. 28. Distal Left Main Bifurcation in a Patient with Low EF  87 Y old Gentleman High 160 cm –Weight 59 Kg  Effort Angina Class III  Hypertension  No Diabetes  Creatinine 2.0 mg%-ml  No prior PCI  No associated medical condition  Positive Exsercise Test at Low Level  EF 25%  Mitral Insufficent grade III  45 mmHg Pulmonary Pressure 67198/12 HSR History
    29. 29. Distal Left Main Bifurcation in a Patient with Low EF Baseline – IABP in place 67198/12 HSR
    30. 30. Distal Left Main Bifurcation in a Patient with Low EF Rotablator – 1.5 mm BURR 67198/12 HSR
    31. 31. Distal Left Main Bifurcation in a Patient with Low EF Following Rotablator toward LCX 67198/12 HSR
    32. 32. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Following Rotablator toward LAD
    33. 33. Distal Left Main Bifurcation in a Patient with Low EF 3.0mm NC Balloon to LAD 67198/12 HSR 2.5 mm NC Balloon to LCX
    34. 34. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Kissing Balloon 3.0mm NC Balloon to LAD 2.5 mm NC Balloon to LCX Stenting LAD 3.0 - 14 mm
    35. 35. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Post Dilatation Prox-LAD Stent with 3.0 mm NC Balloon Following LAD Post Dilatation
    36. 36. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Struts open toward LCX
    37. 37. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR 2.5 – 8 mm to LCX With TAP Technique
    38. 38. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Stenting LCX Kissing Balloon
    39. 39. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Final Result
    40. 40. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSRFinal Result
    41. 41. Baseline 27287/09CCC
    42. 42. Baseline 27287/09CCC
    43. 43. Baseline 27287/09CCC After stent Resolute 2.5x12mm
    44. 44. 27287/09CCCAfter stent
    45. 45. 27287/09CCC Predilation of LAD with wire protection of 2 Septals, Intermediate and Circumflex
    46. 46. 27287/09CCCResolute 3.5x30mm
    47. 47. 27287/09CCC Kissing Inflation after stenting of LAD towards LM LAD 3.5mm balloon LCX 2.5mm balloon Ramus 2.0mm balloon
    48. 48. 27287/09CCC After Kissing Inflation and LAD stenting
    49. 49. 27287/09CCC After Kissing Inflation intermediate Distal LM
    50. 50. 27287/09CCC T stenting towards Cx and Intermediate with 4 mm Balloon inflated in LAD
    51. 51. 27287/09CCC LAD: 4.0mm balloon LCX : 2.5x30mm Resolute Ramus : 2.5x30mm Resolute
    52. 52. 27287/09CCC LAD: 4.0mm Quantum -23 Atm LCX : 2.5mm Quantum 25Atm Ramus : 2.5mm Quantum 25Atm High pressure NC Balloons postdilation
    53. 53. 27287/09CCC Intermediate LCX Distal LM
    54. 54. 27287/09CCC Distal LM Intermediat e
    55. 55. 27287/09CCC Final Result
    56. 56. 27287/09CC Final Result
    57. 57. 27287/09CC Final Result
    58. 58. 1. Occlusion of the LAD or of the RCA which cannot be opened by PCI and with viable myocardium. Chronic occlusion of the RCA and sometimes even of the LAD can left untreated in elderly people with reduced physical activity. 2. Complex and calcific distal left main bifurcation and the PCI operator does not feel confident to treat or she/he does not expect to obtain a good final result 3. Long diffuse disease in the proximal LAD (needs a stent longer than 30-35 mm) in a patient with diabetes mellitus 4. A patient who has or may have problems with dual antiplatelet therapy Conditions were CABG may be a better choice compared to PCI in patients with Left Main Stenosis:

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