4/19/2014 How To Improve left Main PCI Outcomes Today: What Every Operator Must know Ali AlMasood Why LM is Particular ?  LM is responsible for supplying • 75% of LV cardiac mass if right dominant type or balanced type • 100% in the case of left dominant  5 – 7% of patients undergoing coronary angiography have LM disease  LM disease treated medically have a 3-year mortality rate of 50% 1 4/19/2014 Why LM is Particular ?  Stent Thrombosis • May be fatal, as high as 2.5% in bifurcation disease  Restenosis (up to one year) • Pre-DES: 7.3% - 34% (Ultima registry) • DES: – 3% (Lefevre, et al.), – 19% (Chieffo et al.), – 30% (Teirstein et al.) NYS Database CABG for Left Main Disease 1997–2000 2 4/19/2014 PREVENT IV Randomized Trial JAMA. 2005 Nov 16;294(19):2446–54 Duke Cardiology Database 3 4/19/2014 The Cleveland Clinic Foundation Data Ellis SG et al. Am Heart J. 1998;135:335–8 In-hospital and long-term mortality after CABG for LM disease Taggart et al. 4 4/19/2014 Clinical outcome after LM stenting with DES A Meta-analysis of ULM Stenting with DES Rate of Mid-term death (%) Biondi AHJ 2008: 155;274 5 4/19/2014 Factors to be Considered in LM Intervention  Prognostic factors • Emergency vs. elective • Low vs. high risk  Technical factors • Isolated vs. LM +3 VD • Ostial/med shaft vs. distal Objectives of LM PCI  Initial procedural success (safety)  Long-term success (limit MACE)  Considerations • Can it be done • 1 stent or 2 • Hemodynamic support vs. no support 6 4/19/2014 Case-1  90 y old male  NSTEMI with ongoing chest pain  Echo • EF 35% • Multiple wall motion abnormalities • No significant valve lesion Spider projection Cranial projection 7 4/19/2014 Should I Do It?  What is the likelihood I can achieve optimal short and long term results?  Entry angle for wiring  Ability to maintain flow in both branches  Consequences of closure • Size of Circumflex • RCA CTO • LV function Mid LAD stenting 8 4/19/2014 Extended V shape stenting 9 4/19/2014 SKS Post dilation Final results 10 4/19/2014 Follow up  After one year admitted to the hospital with fast AF  ?? D/C ASA and start Warfarin in addition to Clopidogrel 11 4/19/2014 Conclusion of this case  Choice of strategy is based on vessel and lesion characteristics • plaque distribution • diameter of the branches • angle  Good Results with Liberal Use of Two Stent Strategy One or Two Stents: CMSE-SICI Unprotected Distal LM  773 patients  60% one stent  Two stents: 40% “T” 40% “Crush” 20% “V”  No difference death, MI  TLR 13% vs. 27%  No differences among two stent techniques  Kissing – 50% decrease in MACE Palminteri et al, Arch Card Int 2008;1:188 12 4/19/2014 Case -2  55 y old male admitted with Post AWMI angina  ECG : S-T changes in the anterolateral wall  Echo : EF 45% , hypokinetic anterior wall 13 4/19/2014 14 4/19/2014 What Should I do ?? Should I Do It?  Heart team ? CABG vs PCI  Which strategy ? Single or two stent  Circulatory support?  further lesion assessment ?? 15 4/19/2014 16 4/19/2014 A B C 17 4/19/2014 D E F 18 4/19/2014 19 4/19/2014 20 4/19/2014 single-stent strategy (provisional stenting) is the preferred strategy plaque is located in the lateral wall (area of low shear stress) while sparing the flow divider region (high shear). PLAD, PLCx, RI,  OCT • Detect the Thrombus ( white Thrombus ) • Edge Dissection ( Tow Dissected edge ) • Plaque rupture  Single stent technique is always preferred if possible 21 4/19/2014 Case -3  88 y old with multiple comorbidities, limited mobility.  Admitted with NSTEMI  Ongoing chest pain with inferior S-T changes 22 4/19/2014 23 4/19/2014 24 4/19/2014 25 4/19/2014 T stenting • the angulation between the two vessels approached 90° • A stent is deployed in the side vessel, making sure to cover the ostium with only minimal protrusion into the LAD. • The LM-LAD lesion is then stented followed by a ‘kissing balloon’ inflation 26 4/19/2014 Take Home message  The first step in safely performing LM PCI is careful patient selection  The global appraisal of the patient: • Clinical presentation • Clinical characteristics • Angiographic characteristics  Selection must be based on medical– surgical consultation (Heart Team concept) and ethics of information. Take Home message  Left main stenting with DES is a feasible and relatively safe procedure  The main limitations are the relatively high revascularization rates in bifurcations with double stents and the uncertainty regarding the duration of double antiplatelet therapy 27 4/19/2014 Take Home message  For lesions located in the body and ostium of LM no disadvantage seems to be present, compared to CABG, in terms of need for repeat revascularization or safety  Technical progress and a growing evidence base make this a promising treatment in certain set of patients 28