Will Bioresorbable Scaffolds Change How We Think About Left Main PCI?

Transcription

1 TCT Sep Sep 2014, Washington, DC - U.S.A Will Bioresorbable Scaffolds Change How We Think About Left Main PCI? Robert-Jan van Geuns, MD, PhD Professor of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands TCT 2014, Washington Tuesday, September 16, 4:47 PM - 4:53 PM

2 Potential conflicts of interest Speaker s name: Robert-Jan van Geuns I have the following potential conflicts of interest to report: Research contracts: Abbott, Boston Scientific, Tryton Speaker/Consulting: Abbott, Boston Scientific

3 What do we think about LM PCI?

4 TCT Sep Sep 2014, Washington, DC - U.S.A Will Bioresorbable Scaffolds Change How We Think About Left Main PCI? Will BVS improve outcome of LM+Syntax >32 patients? Robert-Jan van Geuns, MD, PhD Professor of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands

5 TCT Sep Sep 2014, Washington, DC - U.S.A Bioresorbable Scaffolds in Left Main PCI Impact of > BVS implants around the world on LM PCI with Syntax <33 Robert-Jan van Geuns, MD, PhD Professor of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands

6 Stent specifications for LM PCI 1. Large diameter Maximum expansion of 3.5 mm BVS = 4.0 mm =12.6 mm 2 Distal LM CSA CCI 2013: James Shand, Simon Walsh

7 Stent specifications for LM PCI 2. Bifurcation treatment (63% of LM in Syntax)

8 Stent specifications for LM PCI 2. Bifurcation treatment (63% of LM in Syntax) Provisional side branch cross-over preferred strategy with POT for apposition in tapered vessel

9 Stent specifications for LM PCI 2. Bifurcation treatment (63% of LM in Syntax) Provisional side branch cross-over preferred strategy with POT for apposition in tapered vessel Required proximal LM diameter for different side branch diameters LAD Side LM Side LM Side LM Side LM Side LM Side LM 3,3 2,3 3,7 2,4 3,8 2,5 3,9 2,6 3,9 2,7 4,0 2,8 4,1 3,4 2,3 3,8 2,4 3,9 2,5 3,9 2,6 4,0 2,7 4,1 2,8 4,1 3,5 2,3 3,9 2,4 3,9 2,5 4,0 2,6 4,1 2,7 4,1 2,8 4,2 3,6 2,3 3,9 2,4 4,0 2,5 4,1 2,6 4,1 2,7 4,2 2,8 4,3 3,7 2,3 4,0 2,4 4,1 2,5 4,1 2,6 4,2 2,7 4,3 2,8 4,3 3,8 2,3 4,1 2,4 4,1 2,5 4,2 2,6 4,3 2,7 4,3 2,8 4,4 Outside IFU of Absorb BVS Outside Expert opinion limits

10 Stent specifications for LM PCI 2. Bifurcation treatment (63% of LM in Syntax) Provisional side branch cross-over preferred strategy Balloon dilatation of side branch if TIMI<2 or chest pain EuroIntervention 2014; 10-online publish-ahead-of-print May 2014 Absorb everolimus-eluting bioresorbable scaffolds in coronary bifurcations: a bench study of deployment, side branch dilatation and post-dilatation strategies

11 Stent specifications for LM PCI 2. Bifurcation treatment (63% of LM in Syntax) Provisional side branch cross-over preferred strategy Balloon dilatation of side branch if TIMI<2 or chest pain Second stent/scaffold as bailout: High crossing profile (1.4 mm) and 90 degree angulations

12 Stent specifications for LM PCI 3. LM is short segment: 8-10 mm Stent should cover ostium Ostial stenting requires High Radial strength* The coronary ostia are particularly prone to stent recoil due to the fibroelastic properties of the aortic wall and the increased frequency of calcification *Topol EJ, Ellis SG, Fishman J, Leimgruber P, Myler RK, Stertzer SH, O Neill WW, Douglas JS, Roubin GS, King SB, 3rd. Multicenter study of percutaneous transluminal angioplasty for right coronary artery ostial stenosis. J Am Coll Cardiol. 1987;9:1214-8

13 Stent specifications for LM PCI 4. Most patient receive > 1 stent 39% in Syntax LM treatment Thin struts provide earlier coverage BMS Strut Coverage at 14 days in Rabbit P=0.05 % P= , Express 132 μm Liberté 97 μm Element 81 μm Express Liberté Thicker struts associated with delayed strut coverage & healing Element

14 Stent specifications for LM PCI 5. LM patient tend to be older patients/nonsurgical patients: Syntax PCI Registry vs Randomized patients: 71.2 vs 65.2 years Higher bleeding risk, preference for less DAPT DAPT duration for new metallic DES is shortened Unknown for BVS

15 Stent specifications for LM PCI 6. Keep it simple: And fast BVS: 2 atm per 5 seconds + 30 sec at max pressure For 16 atm: sec: 70 seconds. BVS requires aggressive predilatation with increased risk of dissections BVS requires postdilatation in calcified lesions

16 Yet, BVS in LM is possible 1. Anatomy suited for single scaffold cross-over 2. Able to tolerate prolonged inflation times 1. Absence of severe heart failure 3. Diameter <4.0 mm 4. LCX small 1. Step-up <0.5 mm 2. Fenestration balloon <2.5 mm 5. Absence of circular ostial calcification 6. Able to maintain DAPT for 12 months

17 Yet, BVS in LM is possible

18 Corrado Tamborino: BRS % OK

19 Thank you for your attention Robert-Jan van Geuns, Peter de Jaegere, Evelyn Regar, Nicolas Van Mieghem, Felix Zijlstra, Roberto Diletti Floris Kauer, Cordula Felix, Yoshi Onuma, Yuki Ishibashi Ramon Rodriguez, Joost Daemen, Bert Everaerts Antonis Karanasos Ron van Domburg