Presentation:

Presented on 11/12/10 with cresendo angina and multi-vessel ischemia on stress MPI. Cardiac cath revealed 3 V CAD and LVEF 60%. Pt underwent successful DES of LCx-OM2 (Xience V 3.0/23mm). Since then pt continues to have class II angina with mild SOB on maximal medical therapy

Prior History:

Hyperlipidemia, Hypertension, Chronic A-fib, ESRD on HD

Medications: All once daily dosage

ASA 81mg, clopidogrel 75mg, ISMN 60mg, atenolol 50mg, diltiazem (controlled release) 360mg, hydralazine 75mg, furosemide 40mg, warfarin 5mg and atorvastatin 20mg

December 21st 2010 Case #4: CM 78 yrs M

Cardiac Cath 11/12/2010:

3 Vessel CAD with mild diffuse LM and LVEF 60%

LAD: 70-80% proximal and 80-90% mid LAD with

70% moderate size diagonal bifurcation

lesions (Medina class 1,1,1)

LCx: subtotal lesion in large size OM2

RCA: 70% proximal and 80-90% distal bifurcation lesion involving 60% RPDA lesion

(Medina class 1,0,1)

SYNTAX score

34

Case 4: cont…

Update in the incorporation of SYNTAX Score (33) for revascularization choices in patients with extensive CAD

• We have incorporated Syntax score in stratifying patients for revascularization choices (PCI or CABG) for advanced CAD and pts with Syntax score 33 who are not high-surgical risk, being preferentially referred for CABG. This practice is further endorsed by the recent presentation of 3-year data of Syntax Trial at TCT 2010, showing CABG arm having significantly lower individual endpoint of death or MI or revascularization versus Taxus DES PCI, in these high Syntax score pts. Hence as per evidence-based guidelines, optimal coronary revascularization to high Syntax score pts should be CABG. Therefore, patients with SYNTAX Score 33 and not having absolute contraindications to CABG (included below), should be taken out of the cath room for discussion regarding choices of revascularization. As a rule, these patients (SYNTAX Score 33) should be categorically recommended for CABG because of survival & MI advantage over PCI. An opinion of a cardiac surgeon will be required if PCI is contemplated in these pts. Only exception to this rule (taking the pt out of the cath room for discussion) could be, if the referring cardiologist (who has to be different then the Interventionalist) is physically present in the cath lab and expresses strong desire against CABG (because of his/her own belief or known wishes of the patient). • Patients with SYNTAX Score 33 but following situations and co-morbidities could be excluded from routine CT surgery consultations:

1) Acute MI (STEMI or Non-STEMI)

2) Age >80 years old

3) Prior CVA/recent TIA

4) Severe COPD (FEV1 <1L) and on chronic bronchodilator therapy

5) BMI >45

6) Participation in IRB approved trial of PCI

• Also patient’s firm refusal for CABG should be entertained only after the CT surgery consultation outside the cath room in the holding area or the telemetry unit.

Cardiac Cath 11/12/2010:

3 Vessel CAD with mild diffuse LM and LVEF 60%

LAD: 70-80% proximal and 80-90% mid LAD with 70% moderate size

diagonal bifurcation lesions (Medina class 1,1,1)

LCx: subtotal lesion in large size OM2

RCA: 70% proximal and 80-90% distal bifurcation lesion involving

60% RPDA (Medina class 1,0,1)

SYNTAX score

34Case 4: cont…

Prior PCI 11/12/2010:

PCI of LCx-OM2 using Xience V (3.0/23mm)Subsequent Course:

- Continued to have Class II symptoms of angina and mild SOB.

- A f/u echo revealed normal LV function and mild MR. PRU 222.

Plan Today:

- PCI of LAD/D1 bifurcation and RCA lesions (SYNTAX Score 31)

Issues Involving The Case

• Appropriate revascularization choice

in high Syntax score pts

• Bifurcation lesion intervention

• Newer imaging modality- OCT

Issues Involving The Case

• Appropriate revascularization choice

in high Syntax score pts

• Bifurcation lesion intervention

• Newer imaging modality- OCT

MACCE to 3-Years Based on Syntax Score TercileMACCE to 3-Years Based on Syntax Score Tercile

Serruys TCT 2010

CABG TAXUS DES

0

10

20

30

%

0-22

12.3

p=0.75p=0.75

23-32 >33

11.2 11.3

16.117.7

8.3

p=0.16p=0.16 p=0.01p=0.01

171 155166181 208 2070

10

20

30

0-22

11.6

p=0.06p=0.06

23-32 >33

18.8

8.4

18.221.1

10.5

p=0.004p=0.004 p=0.006p=0.006

171 155166181 208 207

RevascularizationRevascularizationDeath, MI or CVADeath, MI or CVA

%

Score:N=

Issues Involving The Case

• Appropriate revascularization choice

in high Syntax score pts

• Bifurcation lesion intervention

• Newer imaging modality- OCT

Prebranch Postbranch Pre- & postbranch

Ostial Prebranch& Ostial

TrueBifurcation

Bifurcation Lesion ClassificationDuke’s Classification

A

FED

B C

Medina: 1,0,0

Medina: 1,1,1 Medina: 0,0,1

Medina: 1,0,1

Medina: 1,1,0

Medina: 0,1,0

Medina Classification

Most common =45%

<5% <5%5-10%

10-15%

15-20% <5%Causes:Plaque shift

SpasmDissection

Bifurcation Stenting: Why There Should be Higher Restenosis with 2 DES vs. 1 DES

In-Segment Restenosis/TLR

restenosis/TL

R

Various Techniques for Stenting Bifurcation LesionsBifurcation

Lesion

Mainvessel

Side-branch

Stent+PTCA Stent+stent(“T stenting”)

Stent+stent(“Y” or “V”)

“V”2

1

1

Stent+stent(“Culotte”)

1 2

Stent+stent(“reverse-T”)

Stent+stent(“Crush”)

2 1

Stent+stent(“Kissing”)

0

5

10

15

20

25 MACE

TLR

%

1SColombo et al.

SES stents(n=85)

13.6

Clinical Outcomes in Trials Comparing One-DES (1S) vs. Two-DES (2S) Strategy in Treating

Coronary Bifurcations

1S 1S 1S 1S 1S 1S2S 2S 2S 2S 2S 2S 2SPan et al.

SES stents(n=91)

Steigen et al.NORDIC Trial

(n=413)

Ferenc et al.T-stenting

(n=202)

Colombo et al.CACTUS trial

(n=85)

Hildick et al.BBC ONE

(n=500)

Sharma et al.PRECISE-SKS

(n=100)

4.5

9.5

2.9

10.98.9

11.912.9

19

2.1

12.8

4.5

11.4

1.9

3.4

15

1.0

5.8 5.6

15.8

5.6

8.0

7.2

15.2

4.0

8.0

12.0

18.0

0

1

2

3

4

5

1S group2S group

%

1SColombo et al.

SES stents(n=85)

Clinical Outcomes in Trials Comparing One-DES (1S) vs. Two-DES (2S) Strategy in Treating Coronary Bifurcations

1S 1S 1S 1S 1S 1S2S 2S 2S 2S 2S 2S 2SPan et al.

SES stents(n=91)

Steigen et al.NORDIC Trial

(n=413)

Ferenc et al.T-stenting

(n=202)

Colombo et al.CACTUS trial

(n=85)

Hildick et al.BBC ONE

(n=500)

Sharma et al.PRECISE-SKS

(n=100)

Incidence of Reported Stent Thrombosis

0 0.40 00

3.5

0.5

1.1

1.7

0

2.0

3.03.0

2.0

Perspectives on Dedicated Bifurcation Stent Designs:

Sidebranch Access - MB Stents

• ABT Pathfinder

• Invatec Twinrail

• Minvasys Nile Pax

• BSC Petal

• Ymed Sidekick

• Antares TriReme Medical

• StentYs

Sidebranch Stents

• Tryton

• Capella Sideguard

Hybrid Stents

• Devax Axxess plus

Perspectives on Dedicated Bifurcation Stent Designs:DES Technology

Sidebranch Access - MB Stents

• ABT Pathfinder

• Invatec Twinrail

• Minvasys Nile Pax

• BSC Petal

• Ymed Sidekick

• Antares TriReme Medical

• StentYs

Sidebranch Stents

• Tryton

• Capella Sideguard

Hybrid Stents

• Devax Axxess plus

A B C

D

A

G I

FE

JH

Bifurcation Stents

Newer Interventions and Stents in 2010

Issues Involving The Case

• Appropriate revascularization choice

in high Syntax score pts

• Bifurcation lesion intervention

• Newer imaging modality- OCT

OPTICAL COHERENCE TOMOGRAPHY: OCT

• OCT provides a super high resolution tool to guide; – proper lumen sizing – full stent apposition– optimal stent expansion

• Fibrous plaque• Calcification • Lipid pool and necrotic core• Macrophages• Thrombus• Thin capped fiberatheroma (TCFA)• Cholesterol, neo-intimal growth, past ruptures.

OCT Imaging of PlaquesOCT Imaging of Plaques

Optical Coherence Tomography

•Vulnerable Plaque

•Coronary Stenting

Berlis and Reglar, European Heart Journal, 2008

Optical Coherence Tomography: Pre-clinical Data

Tearney G, et al. 2008 (Personal Communication)

OCT Vs. IVUS

OCT IVUSResolution 10 µm 100 µm

Penetration* 2 mm 10 mm

Field of View 7 mm 10 mm

Frame Rate 20-40 FPS 30 FPS

ProfileSub 3 F catheter

3.2 F catheter

Scan Pattern helical helical

* OCT penetration requires blood clearance.

Definition of Definition of TThin hin CCap ap FFibroibroAAtheroma theroma TCFATCFA

TCFATCFA

Necrotic Core >10% in Contact with LumenPercent plaque area > 40%

Ivus-VHIvus-VH

Sawada T, Shite J, Garcia-Garcia H, Serruys PW, Irata K-I Sawada T, Shite J, Garcia-Garcia H, Serruys PW, Irata K-I –– Eur Heart J Eur Heart J 2008;29:1136-462008;29:1136-46

LP

F

Cap thickness; 60μm

Fibrous Cap Thickness <60μm

OCTOCT

TCFATCFA

NCCLNCCL

Sawada T, Shite J, Garcia-Garcia H, Serruys PW, Irata K-I Sawada T, Shite J, Garcia-Garcia H, Serruys PW, Irata K-I –– Eur Heart J Eur Heart J 2008;29:1136-462008;29:1136-46

Vulnerable Plaque in 2010:Still a Valid Concept?

7/06

1/07

Optical Coherence Tomography

•Vulnerable Plaque

•Coronary Stenting

OCT: Neointimal Stent Strut Coverage

28

Tissue thickness covering (75 mm)

Tissue thickness covering (250 mm)

Clinical Trial Endpoints to document “healing” and endothelization

Qualitative and quantitative descriptions of stent “healing” are developing

Better imaging assists better clinical decisions

• OCT provides excellent resolution for visualization of vulnerable plaque and optimal stent apposition and strut coverage.

• OCT can also identify plaque prolapse and early stent thrombosis.

• Recent Advances using OFDI makes it easy and facilitate clinical use (flushing).

Conclusions

Take Home Message:Techniques For Complex High-risk PCI

Newer Imaging techniques such as OCT may help us in future to better manage our PCI cases especially DES as regards to the DAPT interruption

Currently mid term (3-yrs) data are unfavorable for DES in pts MVD with Syntax score of >33. These pts should preferentially be referred for CABG

Bifurcation lesion interventional techniques continue to evolve with 2-DES technique should be decided upfront (in long, angulated, large SBr lesion) rather then bail-out strategy and if done correctly, is no longer associated with higher SAT or restenosis vs. 1-DES strategy

Optimal techniques and strategy are crucial to avoid any potential complications in complex cases