无保护左主干分叉病变介入治疗策略 The Principles & Strategies for Treatment of Unprotected LM Bifurcation Lesions Lianglong Chen MD PhD FACC Dept. of Cardiology, Union Hospital, Fujian Medical University

CONTENTS & FOCI Special issues associated with LMD & special considerations Different strategies and techniques for the Intervention of UPLMD Comparison of PCI versus CABG for the treatment of UPLMD Current guidelines and recommendations for the treatment of UPLMD

Why left main lesion is particular? LM is responsible for 75% myocardial blood supplying LM is anatomically big with 2 bifurcation & larger angulations LM is rich in elastic tissue Plaque is usually located in the lateral wall close to the LAD and LCx bifurcation, the carina is frequently free of disease. Plaque of LMD is more diffuse Low shear- stress zone High shear- stress zone carina

Why left main lesion is particular? Plaque of LMD is more diffuse, 90% LM plaque extended to LAD

Special considerations for UPLMD Intervention Reliable branch protection Protecting wire Protecting balloon Effective lesion preparation Pre-dilation Pre-cutting balloon Pre-rotablation First & final balloon kissing DK-crush DK-culotte Special imaging IVUS guiding procedure FFR guiding procedure

Culottes: DK-Mini-Culottes

FBKI: key determinants of restnosis, thrombusis, MI

CONTENTS & FOCI Special issues associated with LMD & special considerations Different strategies and techniques for the Intervention of UPLMD Comparison of PCI versus CABG for the treatment of UPLMD Current guidelines and recommendations for the treatment of UPLMD

Different strategies for the Intervention of UPLMD Simple vs complex Mono-stent vs dual-stents

MACE and TLR in Bifurcation Studies CACTUS BBC ONE BBK Nordic P=0.009

Double vs. Single Stenting Meta-Analysis N=1642 pts 2 stents 1 stent 2 stents 1 stent Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:409-415

Double vs. Single Stenting Meta-Analysis N=1642 pts 2 stents 1 stent 2 stents 1 stent Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:409-415

Shao-Liang Chen EuroIntervention 2012;8:803-814 Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique To compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions Shao-Liang Chen EuroIntervention 2012;8:803-814

MACE-free survival rates at 5-year follow-up

Survival rates free from cardiac death, MI, and TVR at 5-year follow-up

Current consensus or guideline recommendation Simple strategies!

UPLMD: Cases

The optimal Path for BL Treatment 

Different techniques for the Intervention of UPLMD Superiority of one dual-stenting technique over the others ?

Nordic II: Rate of Restenosis (≥50% diameter stenosis by QCA) at 8M In-segment In-stent

Nordic II: Major Adverse Cardiac Events at 6 Months Follow-up Cumulated MACE rate (cardiac death, MI, TVR, stent thrombosis) Crush 4.3%, Culotte 3.7% (plog-rank=0.87). Erglis A et al. Circ Cardiovasc Intervent, 2009; 2:27-34

Shao-Liang Chen, et al. J Am Coll Cardiol 2013;61:1482–8 Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions Results From a Multicenter, Randomized, Prospective DKCRUSH-III Study Shao-Liang Chen, et al. J Am Coll Cardiol 2013;61:1482–8

DK-crush vs classic culotte TLR TVR MACE

Conclusions Classic culotte stenting for UPLMCA bifurcation lesions was associated with significantly increased MACEs, mainly due to the increased TVR.

Shao-Liang Chen EuroIntervention 2012;8:803-814 Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique To compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions Shao-Liang Chen EuroIntervention 2012;8:803-814

Survival rates free from MACE, TLR, and TVR at 5 years between DK crush and other two-stent techniques MACE TLR TVR

Major limitation of classic culotte：CUEB D4.0 D2.5

Culottes: DK-Mini-Culottes

DK-Mini-Culottes: no CUEB

Long-term results at F/U 61 pts Lesion characteristics with 85%TBL, 25% UPLM. Branch diameter difference 0.450.24. DK-Mini-Culottes Immediate technical success 100% FKBI 100% Acute IST 0.0% F/U 11.31.5 M Binary re-stenosis Main branch 6.6% Side branch 16.4% MACE Death 0.0% MI 0.0% TLR 3.2% Late IST 0.0%

Different techniques for the Intervention of UPLMD Superiority of one dual-stenting technique over the others ???

CONTENTS & FOCI Special issues associated with LMD & special considerations Different strategies and techniques for the Intervention of UPLMD Comparison of PCI versus CABG for the treatment of UPLMD Current guidelines and recommendations for the treatment of UPLMD

MACCE to 5 Years by SYNTAX Score Tercile Low Scores (0-22)

MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (33)

Patient Characteristics CABG N=897 PCI N=903 CABG Registry N=644 PCI Registry N=192 P value Age* (y) Male, % Diabetes*†, % Additive euroSCORE* Total Parsonnet score* 65.0±9.8 78.9 24.6 3.8±2.7 8.4±6.8 65.2±9.7 76.4 25.6 3.8±2.6 8.5±7.0 0.55 0.20 0.64 0.78 0.76 65.7±9.4 80.7 26.4 3.9±2.7 9.0±7.1 71.2±10.4 70.3 30.2 5.8±3.1 14.4±9.5 Total SYNTAX Score 29.1±11.4 28.4±11.5 0.19 37.8±13.3 31.6±12.3 Mean # of lesions 3VD only, % Left main, any, % Total occlusion, % Complete revasc, % 4.4±1.8 66.3 33.7 22.2 63.2 4.3±1.8 65.4 34.6 24.2 56.7 0.44 0.70 0.33 0.005 4.6±1.7 59.7 40.3 56.4 74.7 4.5±1.8 66.7 33.3 36.5

MACCE to 5 Years by SYNTAX Score Tercile Low Scores (0-22) CABG (N=275) TAXUS (N=299) CABG 10.1% PCI 8.9% P value 0.64 Overall Death 50 Cumulative Even Rate(%) CVA MI Death, CVA or 4.0% 4.2% 14.9% 1.8% 7.8% 16.1% 0.11 0.81 32.1% 28.6% P=0.43 25 12 24 36 48 60 Months Since Allocation Revasc. 16.9% 23.0% 0.06 Cumulative KM Event Rate ± 1.5 SE; log-rank P value Core lab-reported Data; ITT population

MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (23-32) CABG (N=300) TAXUS (N=310) P=0.008 CABG 12.7% 3.6% PCI 13.8% 2.0% P value 0.68 0.25 Overall 36.0% Death CVA 50 Cumulative Even Rate(%) MI Death, CVA or 3.6% 18.0% 11.2% 20.7% <0.001 0.42 25 25.8% 12 24 36 48 60 Months Since Allocation Revasc. 12.7% 24.1% <0.001 Cumulative KM Event Rate ± 1.5 SE; log-rank P value Core lab-reported Data; ITT population

MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (33) CABG (N=315) TAXUS (N=290) P<0.001 CABG 11.4% PCI 19.2% P value 0.005 Overall Death 50 Cumulative Even Rate(%) CVA MI 3.7% 3.9% 3.5% 10.1% 0.80 0.004 44.0% 25 26.8% Death, CVA or MI 17.1% 26.1% 0.007 12 24 36 48 60 Months Since Allocation Revasc. 12.1% 30.9% <0.001 Cumulative KM Event Rate ± 1.5 SE; log-rank P value Core lab-reported Data; ITT population

SYNTAX UPLMD subgroup analysis at 3 years The UPLMD subgroup (N=705); despite higher TVR for the PCI group at 3 yrs (20.0% PCI vs 11.7% CABG; P=0.004) and lower stroke in the PCI group (1.2% PCI vs 4.0% CABG; P=0.02); Death (7.3% PCI vs 8.4% CABG; P=0.64), MI (6.9% PCI vs 4.1% CABG; P=0.14), and the composite end point of death/MI/stroke (13.0% PCI vs 14.3% CABG; P=0.60) remained similar between groups. These results are consistent reporting similar safety outcomes between PCI and CABG but a higher rate of TVR with PCI.

Rev Bras Cir Cardiovasc 2013;28(1):83-92 Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease Rev Bras Cir Cardiovasc 2013;28(1):83-92

Odds ratio and conclusions plot of endpoints associated with CABG versus DES 死亡、MI、中风 死亡 MACE TVR

Conclusion CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up

FREEDOM Design

Primary Outcome-Death/Stroke/MI

Outcomes 全因死亡 MI 中风 TVR

Primary Outcome-Death/Stroke/MI

Conclusion For patients with UPLMD complicating DM, CABG surgery is the only best option of treatment with no more requirement of Syntax score

CONTENTS & FOCI Special issues associated with LMD & special considerations Different strategies and techniques for the Intervention of UPLMD Comparison of PCI versus CABG for the treatment of UPLMD Current guidelines and recommendations for the treatment of UPLMD

2011 ACCF/AHA/SCAI Guideline for PCI: recommendations

Thanks!