0. Hungary Presents: Use of Imaging for Left Main PCI Optimization
István F. Édes MD PhD
Semmelweis University Heart and Vascular Center
Budapest, Hungary

1. Disclosure Statement of Financial Interest
I, István F. Édes DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

2. Left Main (LM) disease
Significant LM disease significantly impacts coronary artery disease (CAD) prognosis
LM revascularization is a difficult decision:
LM size and disease severity
Complexity of the LM lesion
Concomitant CAD and other disease
Clinical manifestation of LM stenoses

3. Left Main treatment
LM treatment in most cases still remains a prime target for the surgeon
PCI
CABG
LM Syntax score <22
I B
LM Syntax score 23-32
IIa B
3VD, LM Syntax score 23-32
III B
I A
3VD, LM Syntax score >32
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4. Left Main treatment
The more severe the issue the less PCI comes into question (Syntax Trial)
But…
Emergency cases (ACS)
Third generation DES
Single stent based prefered strategies
Better patient selection
Better DAPT (prasugel & ticagrelor)
Availablity of routine intravascular imaging

5. Intracoronary imaging - guidelines
ACC
Class IIa
IVUS is reasonable for the assessment of angiographically indeterminant left main CAD. (Level of Evidence: B)
IVUS is reasonable to determine the mechanism of stent restenosis (Level of Evidence: C)
Class IIb –
IVUS may be reasonable for the assessment of non–left main coronary arteries with angiographically intermediate coronary stenoses (50% to 70% diameter stenosis). (Level of Evidence: B)
IVUS may be considered for guidance of coronary stent implantation, particularly in cases of
left main coronary artery stenting. (Level of Evidence: B)
IVUS may be reasonable to determine the mechanism of stent thrombosis (Level of Evidence: C)
ESC
IVUS / OCT
In case of stent restenosis and thrombosis– Class IIa, LoE: C
LM PCI with IVUS initally grants better short term results
IVUS guided PCI decreased stent thrombosis and restenosis rates

6. Invasive imaging pros and cons
Intravasular Ultrasound
20-60 MHz frequency
Ultrasound technique
~ µm resolution
6-7 mm penetration
Real-time imaging
Calcification
NURD
Spasm
Optical Cohoerence Tomography
300 nm range
Light based technique
~10-15 µm resolution (cellular level)
2-3 mm penetration
Penetration through calcification
Non real-time
Contrast flush need
LM imaging
Preferred modality: IVUS! 6

7. When and how to use IVUS in the LM?
Recommendation
LM PCI planned
To assess severity: IVUS alone may not be optimal, as functional testing and/or ischaemia induction may be needed. But, aim for a target MLA: <6 mm2
Pre-PCI: Evaluate LM size, calcification, fibroelastic components, bifurcation (bi-directional IVUS) and ostial status.
Post-PCI: Evaluate stent edges, apposition, need for post-dilation, bifurcation geometry.
Determine pre-PCI IVUS characteristics
IVUS no-cross
Predilate
Bifurcation disease
Non-bif. disease
IVUS again
IVUS both ways
Optimally prepare LM lesion
IVUS both ways, optimize stent as needed
Apply stents (one preferred)

8. Pre-PCI imaging: more tips&tricks
Ostial lesion?
Assess amount of calcium, fibrous tissue
Shaft lesion?
Carefully verify if bifurcation and ostium are truly unaffected
Bifurcation lesion?
Focus on the degree of bi-directional disease (plaque burden)

9. Post-PCI imaging: more tips&tricks
Ostial stent?
Assess prolapse of stent into the aorta, create a cone as needed
Shaft stent only?
Very carefully assess if bifurcation and ostium are truly uncovered
Bifurcation stents?
Concentrate on the neo-carina

10. Thank you for your attention!