The document discusses approaches to bifurcation lesions in coronary arteries. It defines a bifurcation lesion as a lesion located at the bifurcation of a main branch and side branch. Some key points discussed include:
- Provisional stenting of the main branch with adjunctive treatment of the side branch is generally the preferred initial approach.
- Double stenting techniques like culotte stenting and crush stenting are more complex but may be needed for large side branches or complex lesions.
- Factors like side branch size, angle of bifurcation, and extent of disease impact treatment decisions between single versus double stenting.
- Techniques for wiring the side branch, optimizing stent placement, and treating
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
A coronary bifurcation consists of a flow divider (carina) and three vessel segments:
The proximal main vessel (PMV)
The distal main vessel (DMV) and
The side branch (SB).
A bifurcation lesion is a major epicardial coronary artery stenosis next to and/or including the ostium of a significant side branch
A significant SB is a branch whose severe narrowing or acute occlusion before or during intervention can cause considerable ischemia or a new infarction area that will worsen the clinical course of a particular patient.
Other important elements to consider that are not inherent in the bifurcation classifications include:
Extent of disease on the SB (limited to the ostium or involving the vessel beyond the ostium)
Its size (over 2.5mm in reference diameter)
Bifurcation angle, and
Disease distribution
Stratification of a given bifurcation lesion
The double kissing (DK) crush technique is better for complex coronary bifurcation
Stenting the side branch (SB)
Balloon crush
First kissing
Stenting the main vessel (MV)
2nd kissing balloon inflation
Careful rewiring from the proximal cell of the MV stent to make sure the wire is in the true lumen of the SB stent is key to acquiring optimal angiographic results
Balloon anchoring from the MV
Alternative inflation and each kissing inflation using large enough non-compliant balloons at high pressure
Proximal optimisation technique are mandatory to improve both angiographic and clinical
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
A coronary bifurcation consists of a flow divider (carina) and three vessel segments:
The proximal main vessel (PMV)
The distal main vessel (DMV) and
The side branch (SB).
A bifurcation lesion is a major epicardial coronary artery stenosis next to and/or including the ostium of a significant side branch
A significant SB is a branch whose severe narrowing or acute occlusion before or during intervention can cause considerable ischemia or a new infarction area that will worsen the clinical course of a particular patient.
Other important elements to consider that are not inherent in the bifurcation classifications include:
Extent of disease on the SB (limited to the ostium or involving the vessel beyond the ostium)
Its size (over 2.5mm in reference diameter)
Bifurcation angle, and
Disease distribution
Stratification of a given bifurcation lesion
The double kissing (DK) crush technique is better for complex coronary bifurcation
Stenting the side branch (SB)
Balloon crush
First kissing
Stenting the main vessel (MV)
2nd kissing balloon inflation
Careful rewiring from the proximal cell of the MV stent to make sure the wire is in the true lumen of the SB stent is key to acquiring optimal angiographic results
Balloon anchoring from the MV
Alternative inflation and each kissing inflation using large enough non-compliant balloons at high pressure
Proximal optimisation technique are mandatory to improve both angiographic and clinical
Bifurcation lesions are common and associated with higher risks of major cardiac events and restenosis after percutaneous coronary intervention (PCI). Treatment requires understanding of lesion characteristics, stent design and therapeutic options. We review the evidence for provisional vs 2-stent techniques. We conclude that provisional stenting is
suitable for most bifurcation lesions. We detail situations where a 2-stent technique should be considered and the steps
for performing each of the 2-step techniques. We review the importance of lesion preparation, intracoronary imaging,
proximal optimization (POT) and kissing balloon inflation
Bifurcation stenting is challenge for intervention cardiologist, understanding of lesion, strategy for stenting, imaging has very important for success.
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
3. APPROACH TO BIFURCATION LEISONS
A ( approach) – between proximal MB & SB.
It defines difficulty in accessing side branch. If this angle more can be ↓ by guide wire
insertion, which facilitates SB access after MB stenting.
B ( between) – between the two distal branches. If it small independently predicts SB
occlusion after MB stenting
5. INCIDENCE
Account for 16% PCI
Procedural complications – 9%
Restenosis as high as 36%
Lower initial success rate
APPROACH TO BIFURCATION LEISONS
6. Technical problems
Difficulty in access to the side branch
Plaque shift
Lesion recoil
Ineffective lumen expansion
High periprocedural complication rate
Sub optimal immediate and long term results
Risk of side branch occlusion
APPROACH TO BIFURCATION LEISONS
8. The outer walls of bifurcation points are subjected to
diastolic flow reversal, which leads to oscillatory shear
stress.
Oscillatory (as versus laminar) shear stress is less
efficient in stimulating eNOS.
Monocytes bind more avidly to areas of oscillatory shear
than to areas subjected to linear shear.
oscillatory shear stress is proatherogenic
The shear stress hypothesis
Hsiai, T.K et al ATVB 2001; 21: 1770
APPROACH TO BIFURCATION LEISONS
13. Limitations of Medina classification
Does not take into account
1. Length of disease in the ostium of the SB
2. Length of the LMCA before the bifurcation
3. Trifurcation
4. Vessel angulation
5. no differentiation is made between a normal segment
(lesion free segment) and a <50% lesion
6. presence of calcifications is not identified
APPROACH TO BIFURCATION LEISONS
19. Major adverse cardiac event (MACE) and TLR incidence in
randomized trials comparing 1-stent (1S) with 2-stent (2S)
strategies.
APPROACH TO BIFURCATION LEISONS
23. BASIC PRINCIPLES
Ramifications of coronary tree follow minimal energy cost in providing
myocardial blood flow.
Relation between 3 diameters is simplified by Finet.
Dprox = (Ddistal + Dside) x 0.678.
APPROACH TO BIFURCATION LEISONS
25. OPTIMAL VIEW
SB ostium is rarely visualized from 2 orthogonal views, and may be
explored from single angle called working view.
For LMCA – RAO or LAO view with caudal inclination.
For LAD – D : AP with marked cranial angulations.
For LCx – OM : slight LAO or RAO with caudal angulations.
For distal RCA : AP with cranial angulations.
APPROACH TO BIFURCATION LEISONS
26. Guide selection
A 6-F guiding catheter can be used if the operator performs a
provisional stenting technique .
Techniques such as the T, the reverse crush, and the step crush can
all be used with a 6-F guiding catheter.
The modified T technique requires at least a 7-F guiding catheter.
Culottes, Y, V techniques require at least 8-F guiding catheters
APPROACH TO BIFURCATION LEISONS
27. ONE OR TWO GUIDEWIRES ?
GUIDEWIRE IN EACH BRANCH - improve patency of SB after MB
stenting.
It also good marker of SB origin in case of SB occlusion after MB
stenting.
It can also be used to reopen SB by pushing balloon over jailed guide
wire.
Best way to avoid SB occlusion – select MB stent diameter according to
distal MB diameter in order to avoid carina shifting.
Wire modifies angle A – thus facilitates guide wire exchange, balloon &
stent advancement.
TULIP – study use of one wire while starting the procedure is a
predictor of SB treatment failure.
APPROACH TO BIFURCATION LEISONS
28. BIFURCATION LESION – a)STENT SIZE ACCORDING TO DISTAL MB REFERNCE
b) STENT SIZE ACCORDING TO PROXIMAL MB REFERENCE RESULT IN CARINA SHIFT
APPROACH TO BIFURCATION LEISONS
CARINA IS USUALLY FREE OF ATHEROMA – risk of side branch occlusion is mainly
because of carina shifting ( rather plaque shifting), when MB stent size distal to bifurcation
is too large.
31. when a wire is needed in the SB?
1) the SB has a narrowing at its ostium.
2) the MB has severe stenosis with a large plaque
burden and the SB originates with an angle of <45°.
3) the ostium of the SB deteriorates after pre-
dilatation of the MB.
APPROACH TO BIFURCATION LEISONS
32. SHOULD WE PREDILATE SB LESION OR NOT?
Kissing balloon predilatation is not recommended because of risk of
extensive dissections in unstented segments.
Predilatation of MB left to discretion of operator based on type of
lesion.
Predilatation of SB is subject of controversy – better avoid.
DRAWBACKS - Because while dilating ostium dissection may develop
prevents access to SB across stent struts of MB stent.
APPROACH TO BIFURCATION LEISONS
34. PROXIMAL OPTIMISATION TECHNIQUE ( POT )
Provides solution to under deployment of proximal MB stent.
Carried out by short bigger NC balloon just proximal to Carina.
Changes the orientation of SB Ostium facilitating the insertion of
guide wire, Balloon & if necessary stent in the SB, as well as projection
of stents in the SB Ostium.
POT is useful in especially in bifurcation lesion with large SB.
APPROACH TO BIFURCATION LEISONS
35. IS KBI NEEDED AFTER SINGLE STENT DEPLOYMENT ?
KBI allows SB ostium treatment & apposition of MB stent struts on SB
ostium.
It also enables correction of stent distortion & inadequate apposition.
Drawbacks : Procedural complexity , stent ovalisation, proximal
dissection.
Final KBI is strongly recommended after complex technique with two
stents, remains controversial in case of single stent.
APPROACH TO BIFURCATION LEISONS
36. HOW TO CARRY KBI APPROPRIATELY ?
Step 1: Insert a free wire in SB through struts of the MB stent, if
possible closest to the carina.
Pre shaping of MB wire, utilisation of POT , use of hydrophilic or more
rigid wire & orientable micro catheter may help.
Hydrophillic wires should not be jailed.
In persistent difficulties advancement & subsequent inflation of very
small balloon over jailed wire may restore flow & help in crossing.
Step 2 : After insertion of free wire in SB, jailed wire must be
withdrawn.
Step 3: Selection of Balloons – Diameter must match 2 distal branches.
Balloons must be sufficiently short & use of NC balloons to ↓
dissection.
APPROACH TO BIFURCATION LEISONS
37. Characteristics of bifurcations with difficult SB access
CAG predictors - severe calcifications,
severe stenosis with a large plaque burden in the proximal MV,
tortuosity in the proximal MV limiting guide wire manipulations,
severe stenosis of the SB ostium(TIMI flow <3) .
Distal bifurcation angle - is an important issue in terms of access to
SBs.
SB wiring is usually easy when angle is < 70°, while access more difficult
if angle > 70°, and can be particularly difficult when it exceeds 90°.
Natural distribution 80±27° for LAD/LCX, 46±19° for LAD /D1, 48±24°
for LCX/OM1 & 53±27° for PDA/PLA, respectively.
APPROACH TO BIFURCATION LEISONS
38. Primary side branch wiring – non complex SB access
J tip angle(L1) is usually modulated
according to the side branch take off
angle.
Length of tip(L2) is usually adjusted
according to diameter of the main
vessel lumen.
APPROACH TO BIFURCATION LEISONS
39. It is usually advisable to wire the branch which appear more difficult to do.
APPROACH TO BIFURCATION LEISONS
40. Complex side branch access
When the problem is a distal wide angle ( LCx take-off from LMCA), a
useful solution is to shape the tip with a wide smooth bend or with a
double bend (later is being more practical when the SB lesion is
tighter).
when the SB take-off is ≥ 90 ° & the stenosis is sub-occlusive -
Ante grade wiring, by pushing the wire directly into the SB.
Pullback wiring.
Other methods for complex SB are - “reverse wire” & Venture catheter.
APPROACH TO BIFURCATION LEISONS
41. Anterograde in MEDINA 1,1,1
(Wide angle & sub occlusive
SB)
Pullback wiring in MEDINA
1,1,1
APPROACH TO BIFURCATION LEISONS
42. Reverse wiring in 0,0,1 with
extreme angle > 150
SB wiring with VENTURE
APPROACH TO BIFURCATION LEISONS
43. Side branch re-wiring after MB stent implantation
The success in SB rewiring is the key point of bifurcation interventions.
Now commonly accepted best way is to wire the side branch by using a
pullback rewiring technique.
Important is to obtain a curve sufficiently wide to let the wire scratch
the MV stent struts.
When difficulty in rewiring changing either the shape of the guide
wire's tip or the guide wire in favor of stiffer or more hydrophilic ones.
Rewiring site may influence the type of MBstent distortion after SB
dilation, as crossing of the distal side cells of the MB stent is associated
to better ostium scaffolding & ↓ need of SB stenting.
APPROACH TO BIFURCATION LEISONS
46. When are two stents needed? Intention to treat
SB when they are relatively large in diameter (>2.5 mm) & territory of
distribution.
Have severe disease that extends well beyond the ostium (≥ 10-20 mm).
Have an unfavorable angle for re-crossing after MB stent implantation.
APPROACH TO BIFURCATION LEISONS
47. 1)Provisional
Mainvessel stenting ± sidebranch angioplasty
(Provisional) T-stenting, TAP,
REVERSE INTERNAL CRUSH, REVERSE CULOTTE.
2) elective
Culotte-stenting
Crush technique (reverse crush)
T TECHNIQUE AND TAP
V STENTING
Y STENTING(SKS technique)
Stenting of Bifurcation Lesions
APPROACH TO BIFURCATION LEISONS
48. DEFINITION OF PROVISIONAL SIDE BRANCH STENTING
Main objective is focusing on MB, while maintaining the SB patency.
Strategy is to deploy stent from proximal to distal segment of MB.
In some cases, stent is deployed from proximal segment of MB to SB
also called as inverted provisional technique.
Advantages –
because of open nature optimally MB & Bifurcation are dealt with single stent.
When necessary 2nd stent can be used for SB with culotte or T stenting
technique.
Procedure can be carried with 6F guiding catheter.
APPROACH TO BIFURCATION LEISONS
49. RELETIVE SIMPLICITY .
REQUIRING SINGLE STENT IN 80-90% OF CASES &
RESULTING IN SIMILAR OUTCOME COMPARED WITH MORE COMPLX
STRATEGIES MADE THIS METHOD GOLD STANDARD.
EVEN FOR THE LM STENTING AS BY SYNTAX DATA.
Drawbacks –
Difficulty in ensuring permanent access to SB.
Potential problems in recrossig stent struts towards the SB in implanting 2nd
stent in the SB after stenting the MB.
APPROACH TO BIFURCATION LEISONS
50. Provisional stenting of Bifurcations:
place a stent in the MB
postdilate the MB stent
at high pressure
place a wire into the SB
results are evaluated
dilatation of the SB and
kissing balloon inflation
APPROACH TO BIFURCATION LEISONS
51. Double stenting techniques which are certainly more complex, time
consuming & expensive than provisional stenting.
None of the RCT’s studies showed a clear advantage for routine double
stenting over a provisional strategy.
Other side of coin is patients with complex bifurcation anatomy such
as large SBs with severe disease extending more than a few mm from
the ostium were not well represented in these trials.
There is still a need for an individualized approach to bifurcation PCI &
that 2 stents are still needed in 20-30% of true bifurcations .
APPROACH TO BIFURCATION LEISONS
elective double vessel stenting
53. The culotte technique
It provides near-perfect coverage of the carina & SB ostium at the
expense of an excess of metal covering in proximal MB.
Best immediate angiographic result & theoretically it may guarantee a
more homogeneous distribution of struts & drug .
Can be used in all bifurcation lesions irrespective of bifurcation angle.
Open-cell stents are preferred when the SB diameter is >3 mm.
Disadvantages –
Complexity in the rewiring of both branches through the stent struts,
Not advisable if both branches are dissected after predilatation.
APPROACH TO BIFURCATION LEISONS
54. Culotte technique
Not advisable when there is large discrepancy in
vessel size between the proximal MB and the SB
because the proximal segment of the SB stent
will not attain good apposition to the vessel wall
of the proximal MB .
Conventional practice - challenged in the Nordic
Stent Technique Study, where the authors
recommended stenting of the MB first to avoid
acute closure of the MB.
This approach guarantees patency of the MB
APPROACH TO BIFURCATION LEISONS
56. The crush technique (SB stent crushed by the MB stent)
immediate patency of both branches is assured & therefore it should be
applied in conditions of instability or when the anatomy appears complex.
should be avoided in wide angle bifurcations.
Only SB has to be re-wired & not both branches as in culotte technique.
The crush technique has evolved and is nowadays performed with less stent
protrusion into the MB (i.e., mini-crush) & mandatory 2-step FKI.
crush” technique can therefore be considered as a sort of simplified “culottes”
technique
The mini-crush may be associated with more complete endothelialisation and
easier re-crossing of the crushed stent.
APPROACH TO BIFURCATION LEISONS
58. 1. Inability to wire the SB.
Make Sure That The Wire Is Directed Towards The Distal
Part But Not The Proximal Part.
If The Primery Guide Wire Failes Try Hydrophilic Wires. If
They Also Fail Consider Tapered Tip Wires(MIRACLE).
2. INABILITY TO PASS BALOON IN TO SB.
USE COMPLIANT MONORAIL 1.5 MM BALOON.
IF FAILS REWIRE SB THROUGH A DIFFERENT SITE AND
RE ATTEMT BALOON CROSSING.
IF FAILS THEN USE FIXED WIRE BALOON SYSTEMS.
Potential failure modes of crush and suggested solutions
APPROACH TO BIFURCATION LEISONS
59. REVERSE CRUSH
TECHNIQUE main reason for performing the
“reverse crush” is
to allow an opportunity for
provisional SB stenting
APPROACH TO BIFURCATION LEISONS
60. Step crush
The final result is basically similar to the one obtainedwith the “standard crush”
technique, with the only differencebeing that each stent is advanced and deployed
separately so that a 6 F guide may be used.
APPROACH TO BIFURCATION LEISONS
61. Dk crush
In the DK crush, kissing balloon (KB) inflation is
performed after crushing the SB stent with a balloon.
This technique facilitates access to the SB in addition to
optimising stent apposition at the SB ostium.
APPROACH TO BIFURCATION LEISONS
63. T- and modified T-techniques
The T-technique is the most frequently utilised to crossover from
provisional stenting to stenting the SB and is most suited to
bifurcations where the angle between the branches is close to 90°.
associated with the risk of leaving a small gap between the stent
implanted in the MB and the one implanted in the SB.
In majority T-stenting technique is performed after MB & provisional
SB stenting for a suboptimal result or flow-limiting dissection in the
SB.
APPROACH TO BIFURCATION LEISONS
67. V & simultaneous kissing stent (SKS) techniques
• Advantages –
Access to both branches is always preserved during the procedure with no need
for rewiring any of the branches.
V-stenting is relatively easy and fast.(ideal in emergencies).
• V-stenting is ideal for Medina 0,1,1 bifurcations with a large proximal
MB that is relatively free from disease & with a <90° distal angle.
• Reserve this technique for patients with a short LMCA free from
disease & critical disease of both the LAD and LCX ostia.
APPROACH TO BIFURCATION LEISONS
68. LIMITATIONS –
balloon barotrauma to the proximal MB.
If a proximal stent is needed almost always the risk of leaving a small
gap.
final kissing inflation is performed there is no need to re-cross any
stent.
Generally try to limit the length of the new carina to < 5 mm.
APPROACH TO BIFURCATION LEISONS
70. Favourable features for provisional stenting
in unprotected LMCA
inSignificant stenosis at the ostial LCX with
MEDINA 1,1,0 or 1,0,0
Large size of LCX with >2.5mm in diameter
Right dominant coronary system
Narrow angle with LAD
No concomitant disease in LCX
Focal disease in LCX
APPROACH TO BIFURCATION LEISONS
71. UNFavourable features for provisional stenting in
unprotected LMCA
significant stenosis at the ostial LCX with
MEDINA 1,1,1; 1,0,1 or 0,1,1.
Diminutive LCX with <2.5mm in diameter
Left dominant coronary system
Wide angle with LAD
Concomitant disease in LCX
Diffuse disease in LCX
APPROACH TO BIFURCATION LEISONS
73. IVUS in bifurcation stenting
Determining anatomic configuration, selecting treatment strategy &
assessing final result are key factors in bifurcation lesion treatment
that may have a significant impact on acute and long-term outcomes.
Furukawa et al demonstrated that side branches showing at IVUS
diffuse plaque around the ostium with >50% stenosis were at higher
risk for occlusion.
SB occlusion was uncommon (<10%) after PCI if no plaque was present
at the side branch ostium.
Important role in the decision-making process when treating a distal
LMCA bifurcation stenosis.
APPROACH TO BIFURCATION LEISONS
74. IVUS guidance for bifurcation lesion PCI
IVUS can select the appropriate stent size and length as well as guiding
the most appropriate technique.
Helpful in optimally expand the stent avoiding stent under-expansion,
malapposition, incomplete lesion coverage & overstretch of stent
diameter.
“Incomplete crushing”, defined as incomplete apposition of side branch
or main vessel stent struts against the main vessel wall proximal to the
carina, was found in > 60% of lesions – mechanism for high restenosis
rate.
Therefore, optimisation of the result in the side branch is still the goal
even in the DES era
APPROACH TO BIFURCATION LEISONS
75. Impact of IVUS guidance on outcome
Park et al in 758 pts - non-LMCA bifurcation lesions : IVUS-guided
stenting significantly ↓ very late stent thrombosis in the DES group,
while it did not have any effect on TLR.
Stent under-expansion, incomplete lesion coverage, edge dissections &
longitudinal plaque shifting, which likely contribute to DES
thrombosis are often missed by CAG & are detected by IVUS.
MAIN-COMPARE registry in LMCA lesions - undergoing PCI of the
LMCA, 77.5% were treated with IVUS guidance.
3-year outcome showed a strong trend towards a lower mortality risk
with IVUS guidance group.
APPROACH TO BIFURCATION LEISONS
76. FFR in bifurcation stenting
Bifurcation lesion is very unique as it is the only lesion in which
stenting is not better than angioplasty & even angioplasty is not better
than a “leave it alone” strategy.
CAG evaluation overestimates the functional severity of jailed SB
lesions in every step of the provisional strategy for bifurcation lesions.
FFR-guided provisional side branch intervention strategy is feasible &
effective.
Functional status of jailed SB lesions after DES implantation does not
change significantly during follow-up.
APPROACH TO BIFURCATION LEISONS
77. CAG evaluation is more difficult for bifurcation lesions due to vessel
overlap, angulations, stent struts across SB & image foreshortening.
It is technically difficult to perform IVUS or OCT in jailed SB lesions.
FFR can be easily measured in bifurcation lesions both before & during
intervention.
CAUTION - When FFR is measured for SB ostial lesions, the influence
of proximal & distal lesions should be considered.
If there is a significant proximal stenosis, FFR overestimates the
severity of SB ostial lesion.
In contrast, FFR underestimates the lesion severity when there is a
significant distal SB lesion.
APPROACH TO BIFURCATION LEISONS
78.
79. Limitations of conventional bifurcation stenting
MV stent distortion by side access
Side branch and wire jailing
Side branch accessibility
Limitations in re-wiring, re-ballooning and stenting
of SB
FKI with danger of dissection
Wire crossings
Incomplete coverage of bifurcational area
Complexity, duration and contrast and X ray exposure
APPROACH TO BIFURCATION LEISONS
103. Conclusion
Bifurcation stenosis pose a technical problem.
The complexity of the lesion treatment lies in SB.
Potential reasons for 1 ̊ or 2ry failure in stenting the SB are :
Presence of gap between the 2 stents
Carina/ Plaque shifting from MB
Injury to SB ostium- excessive balloon artery ratio
APPROACH TO BIFURCATION LEISONS