m.lesiak, eu perspective on left main - the final frontier
TRANSCRIPT
EU Perspective on Left Main -The Final Frontier
Maciej Lesiak, MD
Department of Cardiology, University of Medical Sciences in Poznan
Disclosure Statement of Financial Interest
• Grant/Research Support• Consulting Fees/Honoraria
• Abbott Vascular• Abbott Vascular, AstraZeneca,
Biotronik, Boston Scientific, Volcano, St Jude
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
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2010 2011 2012 2013 2014 2015 2016 (9mo)
PCI PCI LM3.9%
3.8%5.6%
6.2% 6.0% 8.4% 12.2%
PCI-LMCA Ist Dept. of Cardiology, Medical University in Poznan
ESC/EACTS Revasc. Guidelines
PCI in Left Main – Meta-analysis
Athappan et al. JACC Cardiovasc Interv 2013;;6:1219-304
Favors PCI Favors CABG
Mortality
1 year 3 years
5 years
Favors PCI Favors CABG
Favors PCI Favors CABG
P=0.26
P=0.80
P=0.13
PCI in Left Main – Meta-analysis
Athappan et al. JACC Cardiovasc Interv 2013;;6:1219-304
TVR at 5 years
Favors PCI Favors CABG
Stroke at 5 years
Favors PCI Favors CABG
MI at 5 yearsP=0.00
P=0.00
P=0.34
Left Main Stem
Large
ShortImportant side branch (LCX is the largest side branch in coronary system)
Wide bifurcation angle
Optimal main vessel stenting an SB protection of crucial importance
Magro M et al. EuroIntervention 2013;8:1259-‐1269
Tryton LM Registry
Retrospective, 9 European centers2008-‐2011 (learning curve)Medina 1,1,1 – 63%
Prospective LMCA Registry
• European collaboration of 8 sites• Large Diameter Device (3.0-3.5 and 3.5-4.0 mm)• Standardized Operation Procedure (SOP)
¡ Post Tryton Deployment ‘POT’ inflation• Angiographic Analysis (Procedural & 6 months)• IVUS Analysis (Procedural & 6 months)• Independent CoreLab analysis• LM > 10 mm
R-J. van Geuns, EuroPCR 2014
Tryton LM PCILimitations Addressed with Current Design
• Procedural reliability¡ Loss of LCx¡ Hemodynamic instability
• Long term durability¡ Restenosis¡ Stent thrombosis
• Impact Main vs Side Branch First Strategy
Addressed with current designs
May require DES Design?
Addressed with current designs
Addressed with current designs
Standard Design: Published Experience
• Safety¡ High Procedural Success¡ No Thrombosis Signal observed (Low numbers)
• Efficacy¡ High Procedural Success¡ TVR = 13%
• All SB (LCx or Ramus)• All RVD <2.3 mm
STANDARD Length (18mm)*
Tryton SHORT Design: Product Details
SHORT Length (15mm)
Design Features• Stent Design: 3 mm shorter main vessel zone• Markers Position Optimized for Large Vessels • Improved delivery system
* Large vessels sizes
4.5mm
3mm
Left Main Clinical Path
Tryton Standard•Studied in e-Tryton and Pivotal Trial
Large Vessel•Studied in Pivotal•Rotterdam Initiated Left Main Study
Left Main Stent (CE)•Designed specifically for ULMCA disease•Facilitates usage with stents up to 6.0mm in diameter
Left Main Clinical Indication (CE)•Evidence supporting “larger vessels”
eTryton Left Main Registry•Real World Usage•POT vs. No KISS•OCT•SHORT stent
Standard Large Diameter Left Main Stent (CE) Left Main Indication(CE) eTryton Left Main Registry SHORT
2008 2011 2013 2014 2016
Confidential
59 YO male patient. Previous MI, HT, DM type IIEF ~30%, ICD
LM restenosis after BVS implantation (LM-LAD)
MV stenting (SB protected, wire removed)
MV DES positioning & implantationPost implantation. Good access to MV
Conclusion
• LMCA stenting more and more common in current practice• LCx - the largest side branch in coronary system• Clinical studies support safety and efficacy of Tryton SB stent compared with provisional stenting in lesions involving large SBs
• LD short design makes Tryton a perfect tool for distal LM stenting
• Drug version very welcome to further improve long term durability