LCX. President / Director of Cardiology / New Tokyo Hospital

Transcription

1 LCX President / Director of Cardiology / New Tokyo Hospital Professor of Department of Advanced Cardiovascular Medicine: Kumamoto University Consultant / National Cardiovascular Center / Osaka Sunao Nakamura FACC, FAHA, FESC, FSCAI

2 72yo F. LMT-CTO, Very Low EF(EF20%) Dx: Course: Coronary Risk F: Renal F: LV Function: Euroscore: UAP/ Chronic Heart Failure 2003 (67 yo) Admission doe to AHF on CHF CAG (LMT CTO EF:19%) Admission due to re-acute HF 2004 (68 yo) re-cag consult Cardiac Surgeon Refuse, refer to Dr. Nakamura HL,Obesity, Current Smoker, FH Cr: 1.12 EF: 20 % %

3 72yo F. LMT-CTO, Very Low EF(EF20%) LVG (EF: 19%) LMT CTO

4 72yo F. LMT-CTO, Very Low EF(EF20%) Collateral angiogram Post PCI

5 72yo F. LMT-CTO, Very Low EF(EF20%) 1 year later No Restenosis, LVEF 19 40%

6 10 Years Later... (after open LMT Chronic Total Occlusion)... -At the same hospital, I met her again, because she wanted to meet me...?? :act of grace by Taiwan Dr.- She survived...

7 Pre

8 Pre Post

9 Pre Post F/U

10 Pre Post F/U EF: 66% No change: pre and post Patients: No Symptom

11 Japanese multicenter registry of CTO PCI 6 Institutions New Tokyo Hospital Department of Cardiology Kumamoto University Department of Cardiovascular Medicine Yamanashi University Department of Cardiovascular Medicine Fukuyama Cardiovascular Hospital Department of Cardiovascular Medicine Suzumoto Genaral Hospital Department of Cardiovascular Medicine Tenyoukai Central Hospital Department of Cardiovascular Medicine Success rate 92.5% Successful CTO PCI 1317 lesions PCI for CTO Jan Dec patients 1424 lesions Unsuccessful CTO PCI 184 lesions Without Clinical follow-up 77 patients/ 80 lesions

12 Long-Term Outcome of Percutaneous Coronary Intervention For Chronic Total Occlusions with DES in New Tokyo Hospital Unpublished Data : Satoru Mitomo, Sunao Nakamura, et al Interestingly, Impact of after procedural revascularization success of cardiac CTO at mortality LAD and RCA fatal prognosis in CTO was PCI improved, according however to CTO it vessels was not changed in the case of CTO at LCX. Cumulative incidents of Cardiac death P=0.005 LAD RCA LCx success unsuccess 20.7% vs. 12.5% Log Rank p=0.005 P<0.001 success unsuccess 25.6% vs. 5.8% Log Rank p<0.001 success unsuccess 0.0% vs. 4.2% Log Rank p=0.55 Follow-up days Follow-up days Follow-up days

13 Hypothesis?? Degree of improvement of fatal prognosis brought by CTO revascularization may differ depending on which artery among coronary arteries is re-vascularized. LCX??

14 The MIlan and New-TOkyo (MITO) Registry Among LMT PCI, some specific cases are still challenged with restenosis and MACE. Seeking for solution of these unsolved challenges, we decided to conduct data review of our own cases. Under the guidance of Dr. Antonio Colombo and Dr. Alaide Chieffo, our staff compiled data of our hospital and that of Milan as MITO Registry. Me Toru DR.Colombo DR. Chieffo

15 MIlan and New-TOkyo (MITO) Registry Between April 2002 and Jun 2015 New-Tokyo n=990 Milan n=520 From 2005 April 2002 April MITO Registry Total 1510 patients 1 st DES N=765 2 nd DES N=745

16 About Long-term Survival After LMT PCI

17 The impact of Main Branch Restenosis on Long Term Mortality Following Drug-eluting Stent Implantation in Patients with De Novo Unprotected Distal Left Main Bifurcation Coronary Lesions: The MIlan and New-TOkyo (MITO) Registry Catheter Cardiovasc Interv Sep 2 by K.Takagi, S.Nakamura A.Colombo et.al Distal LAD-ISR Both LAD and LCX-TLR LCx ostial ISR alone 30% LAD-TLR 9.2% at 2-years 60% LCX-TLR

18 Kaplan Meier 8-year patients survival n=753 No restenosis N=318 Cumulative Event Rate No Angio F/U N=318 No angiographic FU N=64 LCX-ISR alone N=64 LAD+LCX ISR N=30 LAD-ISR alone N=23 Log rank P<0.001 Days Since PCI

19 Lesson 1 Among restenosis after LMT PCI, restenosis at LCX ostium is not directly link to fatal prognosis in most of the cases. Therefore our focus should be shift to restenosis at LM toward LAD, which strongly affect on patientsʼ fatal prognosis. Letʼs think about RCA???

20 Impact of residual chronic total occlusion of right coronary artery on the long-term outcome in patients treated for unprotected left main disease: the Milan and New-Tokyo (MITO) registry. Circ Cardiovasc Interv April;6(2); by K.Takagi, S.Nakamura A.Colombo et.al 523 Pts LMT-PCI No CTO RCA 46 Pts LMT-PCI Residual RCA CTO

21 Cumulative event rate at 5 years follow-up by Kaplan-Meier Method: No RCA CTO and RCA CTO (A) Cardiac-death (B) Cardiac-death + MI (C) MACE Log Rank P=0.001 Log Rank P<0.001 Log Rank P=0.861 Log Rank P=0.001 Log Rank P<0.001 Log Rank P= % at 5-years Residual RCA-CTO 20.8% at 5-years 22.7% at 5-years 28.4% at 5-years NO 6.2% RCA-CTO at 5-years 8.1% at 5-years No at Risk (1) (2) 1-year years years No at Risk (1) (2) 1-year years years No at Risk (1) (2) 1-year years years (1) ULM without residual CTO-RCA (ULM with no CTO-RCA + ULM with treated CTO-RCA ) n=522 (2) ULM with residual CTO-RCA n=46

22 Lesson 2 Following PCI of LMT, cardiac-death occurred more frequently in patients with residual CTO-RCA, v while a few cardiac death occurred in patients without residual CTO-RCA. These findings may suggest that recanalization of CTO-RCA may impact v on the long-term cardiac mortality in patients with LMT-PCI.

23 Long-term Clinical Outcome of Single-stent Crossover Technique from Unprotected Left Main Coronary Artery to the Left Circumflex Coronary Artery Naganuma T, Chieffo Alaide, Nakamura S, Colombo A, et al. Catheter Cardiovasc Interv Comparison of LCX ost and LAD ost after Stenting LMCA * LAD LMCA * LAD LCx LCx Ø Restenosis at the LCx-ostium in LMT-LCx stenting group Ø Restenosis at the LAD-ostium in LMT-LAD stenting group

24 Cumulative event rate of TLR at 3 years follow-up by Kaplan-Meier Method Log-rank p <0.001 LMCA-LCx LMCA-LAD TLR(%) 20 Restenosis at LCx-ostium 18.2% 10 Restenosis at LAD-ostium 3.0% No. at risk LMCA-LCx LMCA-LAD Follow-up (years)

25 Lesson 3 LCX ostium itself independently shows high restenosis rate in patients with LMT-PCI. Now we donʼt have consensus for treating LCX ost. Prox. How about BRS???

26 Previous DES 3.0 NC Balloon pre Dilatation BVS 3.5 x 12mm 3.5mm NC balloon

27 Final Angiogram

28 Only 6month later Severe Restenosis in LCX ost.

29 A LAD previously implanted DES 3.5x12mm BVSLCx C D E F GH I C D E F G H I B LAD Small SB LCx J LAD F F overlapping struts LAD Small SB J no struts LM LM LCx LCx C D E F G H I C D E F G H I C D E neo-carina C D E neo-carina overlapping struts LAD G H I SD: 3.03/3.14mm SA: 7.45mm 2 LAD G H I SD: 2.26/2.71mm SA: 5.01mm 2 Small SB overlapping struts Small SB

30 BVS may not be an optimistic solution for an ostial LCX lesion F F overlapping struts no struts

31 Do not chase to much!! LCX is a different animal This is very unique part of coronary artery!!! So called, HINGE POINT... But point is moving and Twitching And not so much important as compared with LAD and RCA for keeping Ejection fraction of the patientʼs HEART

32 About Endothelial activation?? - Letʼs Think about Jailed Strut in LCX Ost.- Letʼs think about 2 stent technique? Is it related with restenotic event?? Yusuke Fujino M.D.

33 3D OCT Image After SES Implantation with inappropriate KBT LCX Malapposed stent struts LMCA Malapposed stent struts LMCA LCX LAD Y Fujino, Marco. A Costa, S Nakamura et al. AHA 2013 scientific session

34 OCT Assessment of LCX ostium at F/U Post PCI malapposed stent struts 9M follow-up A B C Neointimal proliferation over the malapposed stent struts A B C Y Fujino, Marco. A Costa, S Nakamura et al. AHA 2013 scientific session

35 Area Narrowing of LCX ostium by 3D-OCT Post PCI Follow-up 8.85mm mm 2 We calculated area narrowing(%) with this formula Area (post) Area (follow-up) Area Narrowing (%) = 100 Area (post) Y Fujino, Marco. A Costa, S Nakamura et al. AHA 2013 scientific session

36 Area Shrinkage of LCX Ostium Sirolimus-Eluting Stent Cypher: Johnson and Johnson Everolimus-Eluting Stent Xience V: abott vascular SES (n=10) EES (n=15) p Value Post-PCI LCX ostium area, mm ± ± M follow-up LCX ostium area, mm ± ± Area Shrinkage (%) 32.4± ± Y Fujino, Marco. A Costa, S Nakamura et al. AHA 2013 scientific session

37 Case: LMT ost.~body stenosis: EES single crossover stenting without KBT LMT Ost~Body Lesion Single Stenting with Xiemce POT, Full Cover W/O KBT

38 EES single crossover stenting without KBT Post F/U E C A E C A B D D B A Post B C D E FFR; 0.78 Neointimal proliferation over the malapposed stent struts A B C D E F/U

39 Lesson 5 How many jailed struts, or how much area that jailed struts occupies in the area of ostium of LCX seems to be a determinant factor of Future Endotherialization for the coverage of these jailed struts. Finishing the case with optimum KBT is very indispensable for LMT bifurcation PCI

40 Optical coherence tomography assessment of in-stent restenosis after percutaneous coronary intervention with two-stent technique in unprotected left main. Fujino Y, Nakamura S, et al Int J Cardiol May 20;219: After 2 Stent Implantation We can see NIH at CARINA area I 90 FD FD FD FD LW LW LW LW A B C D II LAD A B C D FD LMC A LW LCX

41 OCT Findings of ISR after Two-Stent Technique Fujino Y, Nakamura S, et al Int J Cardiol May 20;219: Protruded NIH of LCX ostium at flow divider side uncovered stent strut LAD C Flow Divider D Flow Divider LMCA Flow Divider A B C D Lateral Wall LCX Lateral Wall Lateral Wall

42 Pre Stent Implantation (physiological) After Stent Implantation (non-physiological) Low Shear Stress Plaque accumulation LW (lateral wall) Implanted Stent Struts accumulation Low Shear Stress Plaque accumulation LW (lateral wall) High Shear Stress FD (flow divider) Neointimal Hyperplasia Neointimal Hyperplasia Uncovered Stent Struts Malapposed Stent Struts

43 Experimental model to study flow pattern Without stent placement Blood flow at carina is quite fast. After stent implantation Flow is delayed, causing turbulence. Without Stent High shear stress (high coronary flow) Culotte Stent Low shear stress (Low coronary flow) This is so-called low shear stress status. It is speculated that stent struts remaining at orifice of circumflex negatively affect the flow.

44 Without stent T- stent Accumulated stent struts might impact the flow pattern then progress the NIH in 2 stent PCI case Crush stent Culottes stent

45 OCT LAD LCX LMCA LCX Unfavorable culotte LAD LMCA Favorable culotte Home Data

46 Favorable culotte Unfavorable culotte LMCA LMCA LAD LAD LCX LCX LMCA LAD LMCA LAD LCX LCX Home Data

47 OCT TAP stenting

48 Follow-up CAG after PCI ISR of LAD proximal ISR of LCX proximal

49 Experimental model to study flow pattern Without stent placement Blood flow at carina is quite fast. Unfavorable TAP stent Flow is roiling, causing turbulence. High shear stress (high coronary flow) Flow Disturbance Home Data

50 Lesson 6 1. As far as bifurcation lesion is untreated, its flow around carina is fast and plaque is not accumulated. 2. However once two stents are placed, flow is delayed and causing turbulence, which is so called low shear stress area, susceptible to plaque deposition. 3. Depending on which double stenting technique is used, flow of CX would be different, and... even whether favorable stenting is achieved or not makes flow pattern different.

51 Happy End... Not Always!!