左主干分叉病变治疗策略的选择 Left main bifurcation: what is the best choice? Lei Ge, MD Department of Cardiology, Zhongshan Hospital, Fudan University

左主干分叉病变治疗策略的选择Left main bifurcation: what is the best choice?

Lei Ge, MD

Department of Cardiology, Zhongshan Hospital, Fudan University

What do we know about the distal LM?

Left main bifurcation: what is the best choice?

Fact #1 – Patients with LM bifurcation lesions have a significantly higher incidence of MACE than patients with ostial and midshaft lesions

T-SEARCH/RESEARCHJ Am Coll Cardiol 2006;47:1530-37

20-month MACE

adj. HR 2.79 (95% CI 1.2-8.9), p = 0.032

n = 130

GISE/SICIEur Heart J 2010;30:2087-94

24-month MACE

adj. HR 1.50 (95% CI 1.1-2.1), p = 0.024

n = 1,111


HR (95% CI) P HR (95% CI) P

Death 1.00 (0.50-1.99) 0.99 0.66 (0.35-1.26) 0.21

Q-MI 1.42 (0.37-5.45) 0.61 0.72 (0.23-2.23) 0.57

TVR 7.71 (1.78-33.4) 0.006 6.23 (3.12-12.4) < 0.001

Death, Q-MI or Stroke 1.06 (0.57-1.99) 0.85 0.95 (0.56-1.82) 0.62

Death, Q-MI, Stroke or TVR 1.51 (0.91-2.49) 0.11 1.42 (1.02-1.97) 0.04

Fact #2 – DES-PCI is associated with a similar higher risk of TVR than CABG either in patients with non-distal or distal LM lesions

Ostium/shaft Bifurcation

Data from the MAIN COMPARE Registry; HR for DES-PCI with reference to CABG

Adapted from Park SJ


SYNTAX Left Main armWhat did it add to our understanding on

Distal LM PCI?


Key findings from SYNTAX (LM PCI cohort)

In distal versus non-distal left main lesions:

No difference in safety (death/CVA/MI)

No significant difference in revascularization rates

Distal vs non-Distal


In distal left main lesions

No difference in safety (death/CVA/MI)

Trend towards higher MACCE driven by more revascularization rate for bifurcation stenting using ≥2 stents versus 1 stent

2-stent vs 1-stentKey findings from SYNTAX (LM PCI cohort)


In distal left main lesions

Equivalent safety

Significantly increased MACCE and revascularization with non provisional T-stenting versus T-stenting

T-stent vs non T-stent

Key findings from SYNTAX (LM PCI cohort)


But... only 12.7% of the randomized SYNTAX cohort received PCI for a distal LM lesion

Huge chance for Type I and Type II errors!


Beyond the SYNTAXLooking for meaningful predictors of

worse outcome relevant to the LM bifurcation cohort

Stenting technique

Plaque distribution and bifurcation angle

SYNTAX score


MA

CE

fre

e su

rviv

al (

%)

100

75

50

25

0

Time (months) 0

12

24

80.0%

72.0%

OSTIUM/SHAFTBIFURCATION

P = 0.035*

1) The case for the stenting technique - LM Bifurcations treated with 2 stents have worse outcomes than LM bifurcations treated with 1 stent

MA

CE

fre

e su

rviv

al (

%)

100

75

50

25

0

Time (months) 0

12

24

80.0%

67.0%

OSTIUM/SHAFT

BIFURCATION, 2 stents

P = 0.38*

BIFURCATION, 1 stent

75.0%

P < 0.001**

* log rank test for ostium/shaft versus bifurcation 1 stent** log rank test for ostium/shaft versus bifurcation 2 stents

* log rank test for ostium/shaft versus bifurcation

Palmerini et al. Eur Heart J 2010;30:2087-94

GISE/SICI Registry (n = 1,111)


Worse outcomes of bifurcation LM PCI are driven by need for revascularization, but only in patients receiving 2 stents

2-year MI 2-year TLR2-year death 2-year cardiac death

P < 0.00001

P = NSP = NS

P = NS

OSTIUM/SHAFT

BIFURCATION, 2 stents

BIFURCATION, 1 stent

Palmerini et al. Eur Heart J 2010;30:2087-94

GISE/SICI Registry (n = 1,111)


Whole Bifurcation (WB)

non-Whole Bifurcation (non-WB)

Plaque Distribution Pattern in LM Bifurcation

Tamburino et al. JACC Interv 2010;3:624-31


24.9%

8.3%

HR: 3.12; 95% CI 1.59-6.11; p = 0.001*Adj. HR 2.84; 95% CI 1.43-564, p = 0.003

Non-WB (n = 145)

WB (n = 184)

2) Plaque distribution pattern in LM bifurcation - Three-year TLR stratified by baseline plaque distribution pattern

Tamburino et al. JACC Interv 2010;3:624-31

Whole Bifurcation (WB)*

non-Whole Bifurcation (non-WB)

*The presence of the plaque at each side was attributed regardless of the stenosis degree


P = 0.028

P = 0.023

P = 0.55 = 0.55

3-ye

ar t

arg

et le

sio

n r

evas

cula

riza

tio

n (

%)

P = 0.29

The Impact of Plaque Distribution Pattern is Independent from the Stenting Technique

P for interaction between plaque distribution and stent technique: NS Tamburino et al. JACC Interv 2010;3:624-31


Capodanno et al. JACC Interv 2009;2:731-8

Ostium/shaft

* After adjusting for confounders: HR 2.89, 1.07-7.85, p = 0.037. ** After adjusting for confounders: HR 6.09, 1.00-36.9, p = 0.049. P for interaction between SYNTAX score, lesion location and treatment:

0.249

P = 0.984

P = 0.001*

Bifurcation

P = 0.839

P = 0.006**

3) The case for the downstream CAD - SXscore predicts 2-year cardiac mortality regardless of lesion location


PCI or CABG?Would you use two stents?

No

Is the bifurcation fully (even subcritically) involved?

Favors CABG Consider PCI

Yes

Yes

No

No

Yes

High SYNTAX score?

1

2

3


Optimal LM Bifurcation PCILesion Preparation and DES Implantation

• Lesion preparation - strongly discourage direct ste

nting; RA for heavily calcified lesion

• DES implantation - 1.0-1.1:1 ratio at appropriate pr

essures for complete apposition…

Strongly recommend IVUS guidance for stent str

ategy, sizing, and optimal implant results (stent

dimensions and apposition)


Optimal LM Bifurcation PCIIVUS Guidance

• Strongly recommended to IVUS both LAD and LCx origins and entire LM segment back to ostium, PRIOR to intervention - PLAN STRATEGY

• In general, LCx ostium lumen area > 4.0 mm2 or plaque burden ≤ 60% indicates acceptable for one stent strategy

• Iterative post-dilatation and IVUS to achieve LM MLA > 8.5 mm2 , origin LAD > 5.5 mm2 , and origin LCx >5.5mm2(2 stents) or >4.0mm2(1 stent)

• IVUS desirable after kissing balloons, esp. origin LCx (if catheter passes easily)


• Single stent crossover provisional technique is strongly r

ecommended whenever possible; post-dilate LM stent with n

on-compliant balloon and also dilate origin of sidebranch if pat

ency questioned (? IVUS or FFR), followed by kissing balloons.

• Provisional second stent - only consider after repetitive kissing

balloon inflations: (1) severe dissection (≥ grade B), (2) TIMI fl

ow < 3, (3) “severe stenosis” = > 70% DS (visual estimate) or I

VUS MLA < 4.0 mm2 with plaque burden > 60%

Optimal LM Bifurcation PCIStent techniques


• Primary two stent technique - should be considered when th

e sidebranch (usually LCx) is large (> 3 mm), with sidebranc

h disease and lesion length > 5mm OR special anatomic co

nsiderations (e.g. severe calcification);

• Technique at operator’s discretion (T-stent, TAP, mini-crush,

culotte), but V-stenting is discouraged

Optimal LM Bifurcation PCIStent techniques


• Kissing balloon dilatations - strongly recommended, usin

g non-compliant balloons;

(1) after crossover single stent at operator’s discretion when

sidebranch patency is compromised

(2) after primary two stent technique with 2-step strategy - fi

rst sidebranch at high pressures, then kissing balloons at m

oderate pressures

Optimal LM Bifurcation PCIKissing balloon


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左主干分叉病变治疗策略的选择 Left main bifurcation: what is the best choice? Lei Ge, MD Department of Cardiology, Zhongshan Hospital, Fudan University