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EAPCI & complex lesions
- 1. EAPCI documents on Complex Lesions Interventions Emanuele Barbato, MD, PhD, FESC EAPCI President-elect Co-Director, Cardiovascular Center Aalst, Belgium Professor of Cardiology, University Federico II, Italy
- 2. Agenda a) Role of IV imaging
- 3. Raber L et al. Eurointervention 2018
- 4. IV imaging & MACE, TLR Raber L et al. Eurointervention 2018
- 5. Di Mario C et al. JACC Cv Intv 2018 IV imaging & CV Death
- 6. Zhang JJ, TCT 2020 IV imaging & TVF
- 7. Myocardial Revasc GLs 2018 ESC Guidelines recommendations
- 8. Raber L et al. Eurointervention 2018 EAPCI recommendations
- 9. Raber L et al. Eurointervention 2018 Considerations on Calcified Lesions
- 11. Raber L et al. Eurointervention 2018
- 12. Johnson TW et al. Eurointervention 2019
- 13. Kobayashi N et al. Cardiol 2017 Calcified Nodules in ACS Sugiyama T et al. JACC Cv Intv 2019 Post-PCI MSA smaller with CN
- 14. Agenda a) Role of IV imaging b) PCI in Complex Lesions
- 18. Gersh BJ, Bhatt DL. Eur Heart J. 2021;42:1387-1400 Gersh BJ et al. Eur Heart J 2021
- 21. Plaque Modification Single, small burr (1.25mm to 1.50mm) Facilitate balloon dilatation and stent implantation Smoothen the lumen and disconnect the calcified coronary ring Barbato E et al. Eurointervention 2015 Main objectives of contemporary RA
- 22. Guide Catheter Selection • Single curve with strong support • Most procedures can be performed with a 6 FR Guiding Catheter Guidewire Selection • Most procedures can be performed with the Rotawire Floppy • Use of regular wire placement, exchange using microcatheter placement often required • It is important to shape the ROTAWIRE tip smoothly Barbato E et al. Eurointervention 2015 Pre-procedural recommendations
- 23. Burr Selection • Single, small burr (1.25 or 1.50 mm) works for the majority of lesions. • Consider a burr-to-artery ratio of 0.6 Pacing Considerations • Positioning a temporary pacemaker should be considered when treating the right coronary artery or dominant left circumflex Barbato E et al. Eurointervention 2015 Pre-procedural recommendations
- 24. Between 135,000 and 180,000 RPM ABLATION SPEED Short duration: individual runs < 30 secs RUN TIME Pecking motion should be used to minimize deceleration BURRING TECHNIQUE Barbato E et al. Eurointervention 2015 Procedural recommendations
- 25. Cocktail with verapamil, nitrates and heparin in saline Sufficient plaque modification to achieve optimal balloon dilatation and stent implantation Should be < 5,000 RPM DECELERATION If the lesion cannot be crossed after several passes DOWNSIZING BURR ROTABLATION FLUSH WHEN TO STOP? Barbato E et al. Eurointervention 2015 Procedural recommendations
- 26. Non Compliant Balloon Rotational Atherectomy Orbital Atherectomy Scoring Balloon High Pressure Balloon Cutting Balloon Laser Atherectomy Intra-Vascular Lithoplasty Courtesy of M. McEntegart Current treatment options
- 27. Emanuele Barbato, MD, PhD Emanuele Gallinoro, MD Flavio Luciano Ribichini, MD, PhD Contemporary management strategies of patients with heavily calcified coronary stenoses An EAPCI position paper in collaboration with EURO4C-PCR working group
- 29. Hamon M, Eurointerv 2013
- 30. EURO 4C registry Bouisset F et al. Eurointerv 2020
- 31. Agenda a) Role of IV imaging b) PCI in Complex Lesions c) Unmet needs
- 34. • EAPCI is actively engaged to generate scientific and consensus documents in order to provide guidance to the interventioncal cardiology community • Implementation of novel diagnostic strategies and therapies is now constantly monitored by EAPCI in order to identify areas of unmet needs deserving particular attention from the relevant stakeholders Conclusion
- 35. Zhang JJ, TCT 2020 IV imaging & TVF
Editor's Notes
- Thank you very much for the kind introduction. I’d like to start thanking both Prof. Di Mario and Tarantini, respectively on the EuroCTO side and on the GISE side for the kind invitation to this joint symposium. After a supplement of reflection with Carlo, we agreed to reshuffle a bit the title of my presentation such that I would be able to share what has been the scientific contribution of EAPCI to the magament of complex coronary lesions through the publication of several position papers and consensus documents ...
- … the topic has been tackled at different levels, starting from the role of IV imaging ...
- … this is the first part of the EAPCI consensus document on the role of intracoronary imaging in guiding and optimizing coronary interventions ...
- ... Where a strong emphasis has been given to its role a tool to further improve clinical outcomes when used to guide and optimize PCI. This is the meta-analysis published whitin the consensus document showing a significant reduction of MACE and TLR with imaging-guided PCI vs. Angiography-guided PCI ...
- … and this is the updated analysis with the inclusion of the 12 months follow-up of the ULTIMATE trial that was published in the meantime where also CV mortality resulted significantly reduced when PCI was guided by IV imaging ...
- … of interest this advantage was particulary clear in challeging lesion settings like MVD, CTO, bifurcation, calcified lesions. In fact, despite the p for interaction is not significant, it is clear that in the challenging lesion settings the gain in terms of improved clinical outcomes after PCI is more pronounced.
- … perhaps the field is more mature to lead to a revisitation of the latest ESC GLs that still give a class IIa LOE B to IVUS not only to assess LM stenosis severity but also to guide PCI in ULM stenosis. IVUS and OCT both receive a class of recommendation IIa with LOE B to optimize stent implantation in selectied patients. Additional guidance is provided ...
- … by the EAPCI consensus document where IV imaging is recommended for diagnostic assessment each time we are in presnce of angiographically unclear or ambiguos findings, in case of LM stenosis severity assessment, complex bifurcation lesion or suspected culrpit lesions of ACS patients. For PCI guidance and optimization, IV imaging is recommended for long lesions, CTO (based on evidences coming from RCTs), while it is expert opinion that IV might be very useful in ACS, LM, complex stenting strategy, in pts with renal dysfunction. And finally, IV imaging is a must for the identification of mechanisms of stent failure ...
- … additional considerations are given to calcified lesions like for example ... (read) ...
- … this information can be readily implemented in clinical practice considering the contermporary algorithm derived from the application of AI to our OCT software that is returning in numbers the extent and severity of lesion calcification to refine more and more PCI guidance ...
- … that should strive to achieve given targets for optimal stent implantation as highlighted in this nice figure integrating key elements like what should be the final MSA, the unacceptable edge dissections, malapposition degree etc.
- … in the second part of the EAPCI consensus document on IV imaging ...
- … Tom Johnson and colleagues focused among other topics on ACS and interestingly on the identificaiton of this novel entity which is the calcified nodule responsible of less than 10% of the ACS cases. The importance of the detection of CN is clear on the KM to the right showing how it is often associated with smaller post-PCI MSA and with lower TLR-free survival ...
- … next point on the agenda is the role of PCI in complex lesions ...
- … EAPCI contributed to the development of the latest GLs on myocardial revascularization ...
- … that tried to provide some guidance on which are the clinical and anatomical characteristics favouring PCI over CABG. Beyond the previous considerations on the role of IV imaging to guide and optimize PCI there is very limited space though dedicated to complex procedures ...
- … for CTO we even have one recommendation of class Iia LOE B in patients with angina resistant to MT or with a large area of documented ischemia in the territory of the occluded vessel, Now, it is easy to think that this recommendation, like more in general the indication to revascularization in CCS patients, might be challenged by the publication of the ISCHEMIA trial ...
- … yet we should not be so pessimistic and I would agree with what recently stated by Bernie Gersh in his recent editorial. There will be no impact of ISCHEMIA trial result on the indications to CAG and revascularization based on the severity of symptoms, as in this case there will a demonstrated improvement in quality of life of the patients, there will be no impact on patients showing severe ishemia on imaging test in addition to stress test features of high risk like for example those indicating the presence of LM disease or LM equivalent. Likewise no consequences in patients with reduced LV function. There might well be consequences on the indication to CAG and revasc based only on positive imaging test alone where ISCHEMIA would first recommend an attempt to OMT, an in case of refractory symptoms still would support revascularization. Finally the results of ISCHEMIA do not apply to patients who have already undergone to CAG where we can still apply anatomic and/or hemodynamic based indications to revascularizations ...
- … for calcified lesionswe don’t have any recommendations but just a small text mentioning to the importance of lesion preparation especially in heavily calcified lesions with more aggresive tools and devices like cutting or scoring balloons or rotatational atherectomy ...
- … here we have our EAPCI consensus document on rotational atherectomy that has clarified the ...
- ... the main objecives of RA that are to achieve good plaque modification and not any longer systematic calcium debulking. This means smoothening the lumen and disconnecting the calcified coronary ring. Something that can be achieved in most of the cases with a single small burr of 1-25 or 1.5 mm, in order to facilitate further balloon dilatation and optimize stent implantation. Technical aspects on how to safely and easily perform plaque modification are further illustrated ...
- … in the consensus document where we also provided some procedural recommendations, I will not go thriugh all of them ...
- … but some are worth to be mentioned, like the selection of the burr size that should follow a burr-to-artery ration of 0.6 more or less. Temporary pacemaker should be considered when treating RCA or dominant LCX, even though it’s not absolutely mandated if you’re confident to manage the situation with a little bit of atropine ...
- … ablation speed should be in the range of 135 to 180 K RPM, and individual runs should be short, preferably below 30 sec each. Burr movement should aim at minimizing possible decelaration of the burr within the lesion, therefore the pecking motion was proposed.
- … deceleration will occur anyhow, but in case this should not exceed more than 5000 rpm, finally when to stop, when we think that sufficient plaque modification was achieved in order to further perform optimal balloon dilatation and stent implantation ...
- … ever since new tools became available like OA, IVL that prompted the preparation of a second EAPCI consensus document ...
- … which is this time dedicate to the contemporary management strategies of pts with calcified coronary stenoses broadening the objectives to different tools and techniques but also the the importance of invasive and non-invasive imaging and some consideration to training and education. This paper is currently ongoing and will become available at the occasion of EuroPCR2022.
- … in this overview I also like to include this old EAPCI consensus document on transradial approach. It was back into 2013, and you can recoqgnize in the authorship 5 EAPCI presidents ...
- … at that time transradial approach was not as much adopted as it is today, neverthless the consensus was that this approach was safe and effectve to be adopted in all-comers PCI including complex procedures, with level 2 dofficulty, being level 3 the ACS patients considered as the most diffcult ones to be catheterized transradially. Now this is a historical slide ...
- … nevertheless it is intriguing to see that after 6-7 years more that 50% rotablator procedures are performed transradially in the countries surveyed in the EURO4C registry, with peaks aroung 80% in countries like France, Spain, or Poland ... Much like in this registry ...
- … EAPCI is also actively enganged to monitor contemporary interventional cardiology practice in order to identify unmet needs that deserve attention from the learned societies, payers, and industry ...
- … we launched in 2018 the EAPCI Atlas with the intent to systematically map and monitor our practice in Europe ...
- … the first results were published in 2020 where interesting insights were provided in our infrastructures, n and type of procedures with related clinical outcomes. The second edition of the EAPCI Atlas with increased n of countries i currently ongoing and will be published by EuroPCR 2022.
- ... Few months ago the 3 years follow-up of the ULTIMATE trial was published at TCT 2020, confirming the superiority of imaging-guided PCI on TLF ...