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Three-dimensional angiography pre- and post- Left Main treatment

4 th EBC Meeting, Prague, 26-27 Sep 2008. Three-dimensional angiography pre- and post- Left Main treatment. Patrick W. Serruys, MD, PhD In collaboration with Chrysafios Girasis, MD Yoshinobu Onuma, MD Thoraxcenter, Erasmus Medical Center R&D Department, Cardialysis

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Three-dimensional angiography pre- and post- Left Main treatment

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  1. 4th EBC Meeting, Prague, 26-27 Sep 2008 Three-dimensional angiographypre- and post- Left Main treatment Patrick W. Serruys, MD, PhD In collaboration with Chrysafios Girasis, MD Yoshinobu Onuma, MD Thoraxcenter, Erasmus Medical Center R&D Department, Cardialysis Rotterdam, the Netherlands Internal document from Cardialysis

  2. Impact of Bifurcation Angle on outcome A high bifurcation angle (>50 degrees) is associated with a greater risk of long term MACE in patients undergoing crush stenting of coronary bifurcation lesions. Dzavik et al, Am Heart J 2006;152:762-9 A narrow LMCA-LCX angle was associated with less expansion of the LCX stent at the ostium ( during crush stenting) and a higher likelihood of incomplete stent apposition. Murasato et al, Catheter Cardiovasc Interv 2007;69:248-256 The most important parameter is the measurement of angles (impact on prognosis). Angle A (between the PMV and the SB) has an impact on the accessibility of the side branch. Angle B (between the two distal branches) has an impact on the risk of SB occlusion during MB stenting. Y. Louvard, TCT 2003 and Catheter Cardiovasc Interv 2008;71:175-183

  3. Potential limitations of previous approaches • Ambiguity of definition: Bifurcation angle in Dzavik’s paper is delineated by the SB and the projection of the PMV. This is an angle by definition narrower to the one between DMV and SB. • Arbitrary cut-off points: Inherent limitation of bench-testing studies studying prespecified angulations (binary approach). Furthermore Murasato et al fail to study the entire spectrum of LM angulation; proximal angle (A) ranging from 90 to 180 degrees. • Subgroup analysis: Information from distinct datasets eg crush stenting. • 2D versus 3D: All but one bench-testing studies, and virtually every QCA study derive their data from two-dimensional analysis.

  4. 3D-QCA Advantages • Objectivity; calculation of reliable data on diameter stenosis, MLD, lesion length, angulation, eccentricity • Avoidance of foreshortening • Avoidance of out-of-plane magnification Requirements • Two clear, separate angiographic projections, being at least 30 degrees apart. If their difference is smaller, a third projection is employed. • Full automatic calibration: elimination of user induced error on calibration

  5. LAD Distal angle Prox angle LCX 3D Bifurcation Angle calculation PrePCI PostPCI Cardiop-B application by Paieon Inc, Israel LAD Distal angle Prox angle LCX

  6. Overview of the presentation • Part I. Modification of Left Main bifurcation angle by systolic-diastolic motion and by treatment. Preliminary exploratory research prior to official submission to the Steering Committee of the SYNTAX trial. • Part II. Long-term follow-up of the Thoraxcenter Left Main population 2000-2005. Impact of the distal bifurcation angle on outcome

  7. LAD 40, 11% LAD LAD LCX 48, 14% LAD LCX 266, LCX LCX 75% fully analyzable partly analyzable non-analyzable SYNTAX Left Main PCI population (n=354) Partly analyzable Non-analyzable Fully analyzable 41 cases 3 cases 2 cases

  8. Pre PCI Post PCI LAD LAD Mean=95,6 SD= 23,9 Med= 96,0 Max= 165 Min= 44 Mean=91,0 SD= 22,2 Med= 91,0 Max= 146 Min= 39 25 25 20 20 LCX 15 15 LCX 10 10 5 5 0 0 75 100 125 150 175 25 50 75 100 125 150 50 (deg) (deg) Distal BA, enddiastolic values (n=266) p<0.001

  9. Distal BA, endsystolic values (n=266) LAD LAD Pre PCI Post PCI LCX LCX Mean=82,8 SD= 21,1 Med= 81,0 Max= 134 Min= 30 Mean=86,7 SD= 23,1 Med= 84,0 Max= 147 Min= 32 30 30 20 20 10 10 0 0 25 50 75 100 125 25 50 75 100 125 150 (deg) (deg) p<0.001

  10. Enddiastolic vs. endsystolic During systolic motion there is an enlargement of the proximal angle and a reduction of the distal angle *p sign <0.05, Wilcoxon signed ranks test, values are in degrees

  11. Rotterdam Left Main population • Unprotected Left Main cases : 207 Elective cases (stable angina): 77 Urgent cases: 130 ( UA=79, MI=51) • Cases analyzable for distal BA: 168 Pre PCI enddiastolic values available: 160 Pre PCI endsystolic values available: 157 • Cases using Drug-eluting stents: 133 Pre PCI enddiastolic values available: 111 Pre PCI endsystolic values available: 110 • Distal Left Main treated (1 or 2 stents pooled): 122 enddiastolic BA available: 97 endsystolic BA available: 95

  12. Rotterdam Left Main population (2) • Elective cases: 77 enddiastolic BA available: 63 endsystolic BA available: 62 • Two stents in the bifurcation: 64 enddiastolic BA available: 55 endsystolic BA available: 55 • Elective cases + distal LM treatment: 45 • Elective cases + two stents: 24

  13. Outcome of Left Main cohorts • Rotterdam LM population outcome at 3 yrs MACE (all-cause death, non-fatal MI, TVR): 44.6% All-cause death: 30.1% TLR: 12.1% TVR: 18.1% • DELFT Registry outcome at 3 yrs* MACE ( cardiac death, non-fatal MI, TVR): 32.1% Cardiac death: 9.2% TLR: 5.8% TVR: 14.2% * Meliga et al, J Am Coll Cardiol 2008;51:2212-9

  14. MACE at 3 yrs-prePCI systolic BA Entire population TXC (n=157) (%) Log rank p-values, tertiles <72 deg vs. 72 - 92 deg, p=0.046 <72 deg vs. ≥ 93 deg, p=0.008 72 - 92 deg vs. ≥ 93 deg, p=0.462 60 52.6% 50 45.4% 40 Cumulative incidence of MACE 28.4% 30 20 10 ≥ 93 deg 72 - 92 deg < 72 deg 0 (yrs) 1 2 3 0

  15. MACE at 3 yrs-prePCI systolic BA Entire population TXC (n=157) (%) Log rank p-values 1st tertile vs. 2nd+3rd tertiles < 72 deg vs. ≥72 deg, p=0.011 60 48.9% 50 40 Cumulative incidence of MACE 28.4% 30 20 10 ≥ 72 deg < 72 deg 0 (yrs) 1 2 3 0

  16. MACE at 3 yrs-prePCI diastolic BA Entire population TXC (n=160) (%) Log rank p-values, median < 82 deg vs. ≥82 deg, p=0.072 60 50 48.3% 40 35.9% Cumulative incidence of MACE 30 20 10 ≥ 82 deg < 82 deg 0 (yrs) 1 2 3 0

  17. MACE at 3 yrs-prePCI systolic BA DES population TXC (n=110) (%) Log rank p-values 1st tertile vs. 2nd+3rd tertiles < 72 deg vs. ≥72 deg, p=0.007 60 50.1% 50 40 Cumulative incidence of MACE 30 25.3% 20 10 ≥ 72 deg < 72 deg 0 (yrs) 1 2 3 0

  18. Conclusions • There is a large variation in the Left Main bifurcation angulation parameters • Systolic-diastolic motion affects the bifurcation angulation • PCI treatment affects the distal bifurcation angle • Endsystolic values of distal BA affect the outcome (MACE) significantly. This is the case both for the entire population as well as for subgroups( DES, distal LM treatment). Enddiastolic values exhibit a strong trend. • Further, in-depth analysis, is necessary

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