pci in left main coronary bifurcation disease -step mini crush tianjin chest hospital wei wang...
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PCI in Left Main Coronary Bifurcation Disease
-Step Mini Crush
TianJin Chest Hospital
Wei Wang Hantao Jiang
Feng XX Male 55Y Chief Complaint : Intermittent Chest Pain for 5 years , aggravate 3 days 。
Risks factors : Hypertension for 5years , smoking for 20y and quit smoking10y 。 Intermittent Alcohol intake 。
Case Information
PE : HR 56 bpm , BP 160/90mmHg
UCG : LA32mm LV54mm LVEF 62%
Decreased diastolic function
LAB : TG 5.19 TC 1.88
HDL 0.97 LDL 3.45
Case Information
75%Stenosis in LMd , 70%-80% stenosis inLADpm, 70% stenosis in LCXp SYNTAX SCORE 28
CAG
IVUS
MLD 2.03mm
MLA 4.41mm2
PB 77% IN LM
MLD 1.78mm MLA 2.93mm2 PB 72% inLADPull back from LAD
IVUS
MLD1.76mm MLA3.64mm2PB 65% in LCX
PCI Equipment
Procedure Approach : TFA 7F sheath
Guiding Catheter : 6F EBU3.75
Guide wires : LAD– Runthrough
LCX– Whispher
Baloon Catheter : 2.5*20mm(Sprinter-Legend)
2.0*15mm(Sprinter-Legend)
3.0*12mm(NC Sprinter)
4.5*8mm(NC Voyager)
Stent : LM--4.0*23mm(Firebird2)
LAD--3.0*29mm(Firebird2)
LCX—3.0*13mm(Firebird2)
PCI
3.0*29mm Firebird2 Stent deployment in LADp to middle ,after predilatation in LADm and LMd
PCI
predilatation in LCXp and LADp, 3.0*13mmFirebird2 stent deployment in LCXp to LMd
PCI
Inflate the baloon in LM, and crush the stent protruded into LM from LCXp
accurate position of ostial LM stent
PCI
4.0*23mm Firebird2 stent deployed from LADm to the ostium of LM
PCI
Rewire LCX , post dilate LADp to ostial LM and LCXp with 4.5*8mm and 3.0*12mm NC baloon separately , final kisssing
PCI
IVUS to check stent apposition from LADm to LM
IVUS
Check stent apposition from LCX to LM
IVUS
COMMENT distal LMCA bifurcation Medina
1,1,1 SYNTAX SCORE 28 CABG or PCI
PCI One or Two Stents
IVUS Pre OR Post
CAD subset CABG favored
PCI favored
1- or 2-vessel disease, nonproximal LAD IIb C I C
1- or 2-vessel disease, proximal LAD I A IIa B
3-vessel disease, simple lesions, full revascularization achievable with PCI, SYNTAX score <22
I A IIa B
3-vessel disease, complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22
I A III A
Left main (isolated or 1-vessel disease ostium/shaft) I A IIa B
Left main (isolated or 1-vessel disease distal bifurcation) I A IIb B
Left main plus 2- or 3-vessel disease, SYNTAX score <32 I A IIb B
Left main plus 2- or 3-vessel disease, SYNTAX score >33 I A III B
Indications for CABG vs PCI in patients suitable for both procedures
Chinese Journal Cardiology,April 2012,Vol. 40 No. 4
LAD=left anterior descending coronary artery
IVUS: LM stenting Always IVUSPRE FOR intermediate lesions FOR Sizing and procedural planning To assess ostial LAD and LCX To determine when(and howmuch)to debulkingPOST IVUS Criteria for optimal stent expansion -LMCA MSA ≥8.5mm -LADo or p MSA ≥6.5mm -LCXo or p MSA ≥5.5mm(≥4.0mm if not stented) -no plaque burden > 50% at a stent edge and no
major edge dissection.If either are present ,stent it!Acute malapposition is not importmant :Don’t chase it! BIGGER IS BETTER------even with DES
THANK YOU
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