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Simple or complex approach ? (Part I)

2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus”. Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) Discussion and Conclusion 1. Are significant side branch lesions really significant ?

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Simple or complex approach ? (Part I)

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  1. 2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus” Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) Discussion and Conclusion 1. Are significant side branch lesions really significant ? Bon-Kwon Koo (Korea) 2. Should we predilate the SB ? Yes A. Hoye (UK) No O. Darremont (France) 3. Jailed wire technique always useful ? Yes G. Stankovic (Serbia/Italy) No F-X Kleber (Germany) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  2. The role of FFR in Bifurcation Lesions Before PCI Main Branch YES (whenever the need for any PCI is doubtful) Side Branch Rarely After PCI Main Branch No Jailed Side Branch Rarely (we have learned Dr Koo’s lesson) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  3. 0.91 0.73 FFR in Bifurcation Lesions: Useful? • 69-y-o man, BMI 36 • Angina during episodes of palpitations • MIBI Spect: reversible ischemia in • the inferior wall

  4. FFR in Bifurcation Lesions: Useful? Before PCI Main Branch YES (whenever the need for any PCI is doubtful) Side Branch Rarely After PCI Main Branch No Jailed Side Branch Rarely (we have learned Dr Koo’s lesson) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  5. FFR in Bifurcation Lesions: Useful? Ostial Diagonal Proximal LAD

  6. FFR in Bifurcation Lesions: Useful?

  7. FFR in Bifurcation Lesions: Useful? Before PCI Main Branch YES (whenever the need for any PCI is doubtful) Side Branch Rarely After PCI Main Branch No Jailed Side Branch Rarely (we have learned Dr Koo’s lesson) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  8. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 1 FFR Diameter Stenosis (%) The angio cut-off value for (jailed) side branches is 75% DS - DS<75%: high NPV - Reason: - radiographic artefact (white halo) - small branches, small myocardial mass, low flow - Most likely idem with non-jailed SB - Oedema ? Like at day one after IMA implantations bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  9. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 1 FFR Diameter Stenosis (%) The angio cut-off value for (jailed) side branches is 75% DS - DS<75%: high NPV - Reason: - radiographic artefact (white halo) - small branches, small myocardial mass, low flow - Most likely idem with non-jailed SB - Oedema ? Like at day one after IMA implantations bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  10. 120 patients, 124 lesions • FFR not measured (n=19) • Slow flow: 8 • Fail to GW passage: 4 • Protocol violation: 6 • AV block: 1 101 patients, 105 lesions • FFR < 0.75: 29 lesions • 26 lesions: Kissing Bln • 3 lesions: No SB PCI • FFR ≥ 0.75: 76 lesions • All lesions: No SB PCI Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 2 70% of the side branches are hemodynamically OK after stenting of the main branch bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  11. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 3 No “FFR late loss” at 6 months bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  12. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 4 “No Kissing” “Kissing” No “FFR late loss” whether or not kissing is performed... But what if no kissing in jailed SB with FFR < 0.75 bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  13. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Take-Home Message 1. The angio cut-off value for (jailed) side branches is 75% DS 2. 70% of the SB are hemodynamically OK after stenting of the MB 3. No “FFR late loss” at 6 monthswhether or not kissing is performed... Side Branches: much ado about nothing bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  14. Are significant side branch lesions really significant? Bon-Kwon Koo (Korea) Missing Information • 1. FFR of the SB immediately after stent deployment in the main • branch may not be representative of the physiology over time: • Recoil • Disappearance of oedema DS • 2. What are the clinical implications in terms of hard end points • Nordic bifurcation trial • BBC ONE trial bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  15. 2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus” Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) Discussion and Conclusion 1. Are significant side branch lesions really significant ? Bon-Kwon Koo (Korea) 2. Should we predilate the SB ? Yes A. Hoye (UK) No O. Darremont (France) 3. Jailed wire technique always useful ? Yes G. Stankovic (Serbia/Italy) No F-X Kleber (Germany) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  16. To predilate or not • For the treatment of true bifurcation lesions, pre-dilatation of the side branch should be undertaken: • To assess how the lesion will behave • May also facilitate subsequent re-wiring • To better evaluate the most appropriate stenting strategy • To reduce the potential for ischaemia during the procedure thereby improving comfort for the patient

  17. To predilate or not • For the treatment of true bifurcation lesions, pre-dilatation of the side branch should be undertaken: 1. If big myocardial mass at risk AND 2. Plaque burden in both branches is high (especially when the distal angle is sharp)

  18. To predilate or not • Using a type B strategy, side branch predilation is not necessary… Three conditions : • Use of « jailed wire » technique • A good knowledge of the stent strut • Final kissing balloon inflation Two exceptions : • Ostial calcified lesion • Long stenosis

  19. 2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus” Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) Discussion and Conclusion 1. Are significant side branch lesions really significant ? Bon-Kwon Koo (Korea) 2. Should we predilate the SB ? Yes A. Hoye (UK) No O. Darremont (France) 3. Jailed wire technique always useful ? Yes G. Stankovic (Serbia/Italy) No F-X Kleber (Germany) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  20. Jailed wire Technique: Simplify the Approach • Modifies favorably the angle between both branches • Keeps the side branch open • Is a good marker of SB • Helps you perform a provisional SB stenting • SB protection decreases myocardial necrosis? ... But most DES are still unsatisfying in terms of stent design especially strut thickness, flexibility and distal distortion during side branch access, but offer a somewhat lower restenosis rate

  21. PCI of Bifurcations Technical Complexity versus Clinical Outcome Result (Clinical outcome?) + • Operator’s experience • Anatomic complexity - Complex Simple 1 Wire + 1 Stent 2 Wires + 1 Stent 2 Wires + 1 Stent + kissing 3 Wires + Predil SB + 1 Stent + kissing Wires + Predil SB + 2 Stents + kissing Crush Culotte etc ...

  22. PCI of Bifurcations Technical Complexity versus Clinical Outcome Result (Clinical outcome?) + • Operator’s experience • Anatomic complexity - Complex Simple 1 Wire + 1 Stent 2 Wires + 1 Stent 2 Wires + 1 Stent + kissing 3 Wires + Predil SB + 1 Stent + kissing Wires + Predil SB + 2 Stents + kissing Crush Culotte

  23. PCI of Bifurcations Technical Complexity versus Clinical Outcome Result (Clinical outcome?) + • Operator’s experience • Anatomic complexity - Complex Simple 1 Wire + 1 Stent 2 Wires + 1 Stent 2 Wires + 1 Stent + kissing 3 Wires + Predil SB + 1 Stent + kissing Wires + Predil SB + 2 Stents + kissing Crush Culotte

  24. 2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus” Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) KISSS principle Keep it Simple Swift and Safe (Adapted from Paul Yock and Bernie Meier) bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  25. 2nd European Bifurcation Club Saturday 30 September morning session: “Breaking the consensus” Simple or complex approach ? (Part I) G. Schuler (Germany), J. Ormiston (New Zealand), Y. Louvard (France) Le contraire du simple n’est pas le complexe mais le faux (The opposite of simple is not complicated, but wrong) André Comte-Sponville Petit traité des grandes vertus PUF, 1995, p201 bernard.de.bruyne@olvz-aalst.be www.cardioaalst.be

  26. Erasmus and Bifurcations PCI • Desiderius Erasmus of Rotterdam, Dutch Humanist and Theologian (1466-1536) • The Praise of Folly (1498) • Treatise on Preparation for Death (1511)

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