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PCI in Left Main Coronary Bifurcation Disease
-Step Mini Crush
TianJin Chest Hospital
Wei Wang Hantao Jiang
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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
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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
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75%Stenosis in LMd , 70%-80% stenosis inLADpm, 70% stenosis in LCXp SYNTAX SCORE 28
CAG
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IVUS
MLD 2.03mm
MLA 4.41mm2
PB 77% IN LM
MLD 1.78mm MLA 2.93mm2 PB 72% inLADPull back from LAD
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IVUS
MLD1.76mm MLA3.64mm2PB 65% in LCX
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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)
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PCI
3.0*29mm Firebird2 Stent deployment in LADp to middle ,after predilatation in LADm and LMd
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PCI
predilatation in LCXp and LADp, 3.0*13mmFirebird2 stent deployment in LCXp to LMd
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PCI
Inflate the baloon in LM, and crush the stent protruded into LM from LCXp
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accurate position of ostial LM stent
PCI
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4.0*23mm Firebird2 stent deployed from LADm to the ostium of LM
PCI
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Rewire LCX , post dilate LADp to ostial LM and LCXp with 4.5*8mm and 3.0*12mm NC baloon separately , final kisssing
PCI
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IVUS to check stent apposition from LADm to LM
IVUS
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Check stent apposition from LCX to LM
IVUS
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COMMENT distal LMCA bifurcation Medina
1,1,1 SYNTAX SCORE 28 CABG or PCI
PCI One or Two Stents
IVUS Pre OR Post
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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
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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
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THANK YOU