PCI for Left Main Disease - bifurc.net · PCI for Left Main Disease Jean Fajadet Cli i P t T l FClinique Pasteur, Toulouse, France Valencia , September 29 , 2007. ... What are we

PCI for Left Main PCI for Left Main PCI for Left Main PCI for Left Main DiseaseDisease

Jean FajadetJean FajadetCli i P t T l FCli i P t T l FClinique Pasteur, Toulouse, FranceClinique Pasteur, Toulouse, France

Valencia , September 29 , 2007Valencia , September 29 , 2007

Treatment of LM diseaseTreatment of LM disease

I.I. What have we learned?What have we learned?––BMSBMS–– DESDES–– DESDES

II.II. What are we doing in daily practice?What are we doing in daily practice?

III.III. How to select patients for PCI or CABG? How to select patients for PCI or CABG?

LM stenting with BMSLM stenting with BMS

InIn--Hospital Mortality RateHospital Mortality Rate


InIn Hospital Mortality RateHospital Mortality Rate(excluding procedures during acute MI)(excluding procedures during acute MI)

0 t 4 3%0 t 4 3%0 to 4.3%0 to 4.3%

Hi h Hi h i k 6i k 6 13% 13% 9%9%« High« High--risk » group: 6risk » group: 6--13% 13% ≈≈ 9%9%« Low« Low--risk » group: risk » group: 00--2% 2% ≈≈ 1%1%


Mid & lMid & l t t litt t litMid & longMid & long--term mortalityterm mortality

FollowFollow--up ranging from 7.3 to 25.5 monthsup ranging from 7.3 to 25.5 months

2% to 2% to 28 %28 %2% to 2% to 28 %28 %


Survival and LVEF Survival and LVEF Cumulativesurvival

1,1

1 01,0

,9

LVEF>40%LVEF>40%,8

,7

LVEF>40%LVEF>40%

,6

,5LVEFLVEF<<40%40%

11001000

900800

700600

500400

300200

1000

,4Log rank analysis Log rank analysis

p= 0.0005p= 0.0005

Boccalatte et al. TCT 2001Boccalatte et al. TCT 2001

DAYS FUP


Predictors of RestenosisPredictors of RestenosisPredictors of RestenosisPredictors of Restenosis

de Lezo J et al. Am J Cardiol 2001.de Lezo J et al. Am J Cardiol 2001.


MACE rate according to Lesion LocationMACE rate according to Lesion Location

1,1

gg

Cardiac Death, Cardiac Death, 1,0

,9

8

89 % 89 % ±± 0.50.5

,,MI, Need for MI, Need for revascularizationrevascularization

,8

,7

,6

Log rank=0.001,5

,4

50 % 50 % ±± 0.80.8NDNon distalNon distalDi t lDi t l,3

,2

,1

DDistalDistal

Mulvihill et al. ESC 2002Mulvihill et al. ESC 2002

3643640

,1

182182


I.I. What have we learned?What have we learned?–– BMSBMS––DESDESDESDES

II.II. What are we doing in daily practice?What are we doing in daily practice?


Unprotected LMCA Unprotected LMCA StentingStenting

Experience with DESExperience with DESArampatzis et al. Am J Cardiol 2003;92:327–329

De Lezo et al Am Heart J 2004;148:481–5

pp

De Lezo et al. Am Heart J 2004;148:481 5.

Chieffo et al. Circulation. 2005;111:791-795.

Park et al J Am Coll Cardiol 2005;45:351– 6Park et al. J Am Coll Cardiol 2005;45:351 6

Agostoni et al. Am J Cardiol 2005;95:644–647

Price et al J Am Coll Cardiol 2006;47:871–7Price et al. J Am Coll Cardiol 2006;47:871 7

Valgimigli et al. EuroInterv. 2007;2:435-443

Fajadet et al Cypher european registry ACC 2007Fajadet et al. Cypher european registry, ACC 2007

Erglis et al. J Am Coll Cardiol 2007;50:491-7

Carrié et al Friend registry ESC 2007Carrié et al. Friend registry, ESC 2007

LM Stenting: Impact of D.E.SLM Stenting: Impact of D.E.S

N at FUN at FU TLRTLRMIMIDeathDeathFU FU (months)(months)

NN(months)(months)

1616

8585

0012%12%6%6%5.15.11717Arampatzis Arampatzis (Research, SES)(Research, SES)

14.1%14.1%__3.5%3.5%668585Chieffo (SES, PES)Chieffo (SES, PES)

2%2%000010210211.711.7102102Park (SES)Park (SES)

5050 2%2%000012125252De Lezo (SES)De Lezo (SES)

5858

340340

7%7%

------

3%3%

1.4%1.4%

5%5%

3.8%3.8%

1414

1212

5858

340340

Agostoni (SES, PES)Agostoni (SES, PES)

Valgimigli (SES, PES)Valgimigli (SES, PES) 340340

228228 6.6% 6.6%

44%44%

%%

3.1%3.1%

10%10%

4.8% 4.8%

10%10%

1212

99

340340

228228

g g ( , )g g ( , )

Fajadet (SES registry)Fajadet (SES registry)

P i (SES)P i (SES) 5050

5050

44%44%

2%2%

10%10%

8%8%

10%10%

00

99

66

5050

5050

Price (SES)Price (SES)

Erglis (PES)Erglis (PES)

151151 2%2%3.3%3.3%2.6%2.6%99151151Carrié et al. (PES)Carrié et al. (PES)


MACE: 2% to 54%MACE: 2% to 54%

InIn--hospitalhospital FollowFollow--upup Total Total (%) (%) (%) (%) (%)(%)

Arampatzis (n=17)Arampatzis (n=17) 1818 00 1818Chieffo (n=85)Chieffo (n=85) 4.74.7 2020 24.724.7Park (n=102)Park (n=102) 0 (6.9%)0 (6.9%)°° 22 2 (8.9%)2 (8.9%)°°De Lezo (n=52) De Lezo (n=52) 44 22 66Agostoni (n=58)Agostoni (n=58) 77 77 1515Registry (n=228)Registry (n=228) 3.53.5 1111 14.514.5Price (n=50)Price (n=50) 1010 4444 5454Price (n=50)Price (n=50) 1010 4444 5454Erglis (n=53)Erglis (n=53) 88 55 1313CarriCarriéé (n=151)(n=151) 3.93.9 3.93.9 7.97.9

°° including nonQWMIincluding nonQWMI

LM Stenting: Impact of D.E.SLM Stenting: Impact of D.E.Sg pg pTLR: 0 to 44%TLR: 0 to 44%

InIn--hospital Followhospital Follow--up up Total Total (%) (%) (%) (%) (%)(%)

Arampatzis (n=17)Arampatzis (n=17) 00 00 00

Chieffo (n=85) Chieffo (n=85) TLRTLR 00 14.114.1 14.114.1

TVRTVR 00 18.818.8 18.818.8

Park (n=102)Park (n=102) 0 0 22 22

de Lezo (n=52)de Lezo (n=52) 00 22 22de Lezo (n=52)de Lezo (n=52) 00 22 22

Agostoni (n=58)Agostoni (n=58) 00 77 77

Registry (n=228)Registry (n=228) 00 6.66.6 6.66.6g y ( )g y ( )

Price (n=50)Price (n=50) 66 38 (I38 (I--D:14%)D:14%) 4444

Erglis (n=53)Erglis (n=53) 00 22 22

CarriCarriéé (n=151)(n=151) 0.70.7 1.31.3 22


Restenosis: 0 to 42%Restenosis: 0 to 42%Distal LM:Distal LM: 00--19%19%Non distal: 0Non distal: 0

Overall (%)Overall (%) Distal (%) Non distal (%)Distal (%) Non distal (%)

Arampatzis (n=17)Arampatzis (n=17) 00 00 00Chieffo (n=85) Chieffo (n=85) 1919 1919 00Park (n=102)Park (n=102) 77 77 00Park (n 102)Park (n 102) 7 7 77 00de Lezo (n=52)de Lezo (n=52) 33 33 00Agostoni (n=58)Agostoni (n=58) __ __ __P i ( 50)P i ( 50) 4242Price (n=50)Price (n=50) 4242 __ __Erglis (n=53)Erglis (n=53) 66 __ __Carrié (n=133)Carrié (n=133) 2.32.3 1.11.1 4.54.5

DES for unprotected LM stenosis DES for unprotected LM stenosis Clinique Pasteur experience Clinique Pasteur experience

September 2002 September 2002 –– August 2006August 2006N 147 ti ti tN 147 ti ti tN=147 consecutive patientsN=147 consecutive patients

Clinical followClinical follow--up: up: 27 327 3 ±±13 2 months13 2 months27.3 27.3 ±±13.2 months 13.2 months

in all patients in all patients

During this period, 168 patients with LM stenosis During this period, 168 patients with LM stenosis underwent CABGunderwent CABG

DES for unprotected LM stenosis DES for unprotected LM stenosis Clinique Pasteur experienceClinique Pasteur experienceClinique Pasteur experienceClinique Pasteur experience

n=147 n=147

Mean age (yrs)Mean age (yrs) 71.08 71.08 ±± 9.989.98Di b tDi b t 26 5%26 5%DiabetesDiabetes 26.5%26.5%Distal lesionDistal lesion 63.9%63.9%EFEF 6262 14%14%EFEF 62 62 ±± 14%14%MVDMVD 76.9%76.9%Stent length (mm)Stent length (mm) 17.6 17.6 ±± 6.8 6.8 CypherCypher 57.1%57.1%TaxusTaxus 39.5%39.5%EndeavorEndeavor 3.4%3.4%

FollowFollow--up up 27.3 27.3 ±±13.2 months (12.113.2 months (12.1--57)57)

%%N (147)N (147)

DeathDeath 1515 10.210.2CV deathCV death 1010 6.86.8

18 418 42727MACEMACE8.28.21212TLRTLR

67.367.39999EventEvent--freefree

18.418.42727MACEMACE

SurvivalSurvival

1-VD

multi-VD

EF≥55%

EF<55% p=0.003 p=0.147

FU months FU months

Non-distal LM CrCl ≥60ml/min

FU months FU months

Distal LM CrCl<60ml/minp=0.78 p=0.058

TLRTLR--free Survivalfree Survival

Non-distal LMDistal LM

CrCl ≥60ml/minCrCl<60ml/minp=0.035 p=0.993

FU months FU monthsFU months

No DM

DM1-VD

lti VD

FU months FU months

DM multi-VDp=0.427 p=0.222

TLRTLR--free Survivalfree Survival

age≥64ys

age<64ys

length>18mmlength≤18mmp=0.033 p=0.124

FU months FU months

Univariate analysisUnivariate analysisMortalityMortalityMortalityMortality

Alive (%)Alive (%) ppDeath (%)Death (%)VariableVariable

6363

26.526.5 NSNS26.726.7DiabetesDiabetes

<0 05<0 055555EF (%)EF (%)

72 072 0

39.439.46363

0.0430.04366.766.7CrCl CrCl <60 mL/min<60 mL/min

0 110 1193 393 3MultiMulti VDVD

<0.05<0.055555EF (%)EF (%)

1 061 06

3.63.6

72.072.0

NSNS1 291 29MLDMLD

NSNS3.73.7RVD (mm)RVD (mm)

0.110.1193.393.3MultiMulti--VDVD

1.061.06 NSNS1.291.29MLDMLD

61.5 0.03791.7Distal LM

Univariate analysisUnivariate analysisTLRTLRTLRTLR

No TLR (%)No TLR (%)TLR (%)TLR (%) p valuep value

27 427 4 0 420 4216 716 7DiabetesDiabetes

42.242.26262

27.427.4 0.420.4216.716.7DiabetesDiabetesNSNS6363EF (%)EF (%)NSNS41.741.7CrCl CrCl <60 mL/min<60 mL/min

3.63.675.675.6 0.200.2091.791.7MultiMulti--VDVD

NSNS3.53.5RVD RVD (mm)(mm)

NSNS1.071.071.271.27MLDMLD< 0.05< 0.0517172222Stent Length Stent Length (mm)(mm)

61.561.5 0.0370.03791.791.7Distal LMDistal LM

Mean age Mean age (yrs)(yrs) 64.864.8 71.671.6 <0.05<0.05

Multivariate analysisMultivariate analysis

Predictor of mortality:Predictor of mortality:EF < 55%EF < 55% OR=4.1, CI=1.5OR=4.1, CI=1.5--11.1, p=0.00611.1, p=0.006

Predictors of TLR:Predictors of TLR:Mean age < 64 yrsMean age < 64 yrs OR=4 1 CI=1 3OR=4 1 CI=1 3--13 p=0 01813 p=0 018Mean age < 64 yrsMean age < 64 yrs OR 4.1, CI 1.3OR 4.1, CI 1.3 13, p 0.01813, p 0.018

Composite distal LM Composite distal LM + Stent length >18mm+ Stent length >18mm OR 3 7 CI 1 2OR 3 7 CI 1 2 12 0 02712 0 027+ Stent length >18mm+ Stent length >18mm OR=3.7, CI=1.2OR=3.7, CI=1.2--12, p=0.02712, p=0.027

Angiographic restenosisAngiographic restenosis

N=17N=17Diff 2Diff 2 S t ti 12S t ti 12Diffuse: 2Diffuse: 2 Symptomatic: 12Symptomatic: 12Focal: 15Focal: 15 Asymptomatic: 5Asymptomatic: 5

MidMid--shaft: shaft: 22LAD ostium: LAD ostium: 1 1 LCx ostium: LCx ostium: 1111Distal LM + LAD & LCx ostia: Distal LM + LAD & LCx ostia: 11Distal LM + LCx ostium: Distal LM + LCx ostium: 2 2


I.I. What have we learned?What have we learned?–– BMSBMS–– DESDES

IIII What are we doing in daily practice?What are we doing in daily practice?II.II.What are we doing in daily practice?What are we doing in daily practice?


Unprotected LM diseaseUnprotected LM diseaseUnprotected LM diseaseUnprotected LM disease

Indications of PCI are based onIndications of PCI are based on

Clinical characteristicsClinical characteristicsage, diabetes, renal function, carotid age, diabetes, renal function, carotid di i di i t ti l ldi i di i t ti l ldisease, previous cardiac intervention, valvular disease, previous cardiac intervention, valvular disease, codisease, co--morbiditymorbidity

Angiographic characteristicsAngiographic characteristicsLV function, distal or no distal LM, trifurcatedLV function, distal or no distal LM, trifurcatedLV function, distal or no distal LM, trifurcated LV function, distal or no distal LM, trifurcated LM, length of LM lesion, calcification, diffuse LM, length of LM lesion, calcification, diffuse disease, MVD, complex lesions (bifurcation, CTO) disease, MVD, complex lesions (bifurcation, CTO) on the other vessels quality of the distal vesselson the other vessels quality of the distal vesselson the other vessels, quality of the distal vessels on the other vessels, quality of the distal vessels

LM stenting techniqueLM stenting techniqueLM stenting techniqueLM stenting technique

Technique of stenting is based on bifurcation anatomy Technique of stenting is based on bifurcation anatomy

distribution of plaquedistribution of plaquebifurcation anglebifurcation anglebifurcation anglebifurcation anglediameter of vesselsdiameter of vesselslength of LMlength of LMlength of LMlength of LMdiffusion of diseasediffusion of disease


I.I. What have we learned?What have we learned?–– BMSBMS–– DESDES

IIII What are we doing in daily practice?What are we doing in daily practice?II.II. What are we doing in daily practice?What are we doing in daily practice?

III.III. How to select patients for PCI or CABG?How to select patients for PCI or CABG?

Unprotected LMCA StentingUnprotected LMCA StentingUnprotected LMCA StentingUnprotected LMCA Stenting

1. Ideal cases for stenting1. Ideal cases for stentingLowLow--risk patients, with good LV function, non distal and non risk patients, with good LV function, non distal and non calcified left main stenosis,calcified left main stenosis,calcified left main stenosis, calcified left main stenosis,

Ostial LMOstial LM

MidMid--shaft LMshaft LM

Ostial Left Main lesionOstial Left Main lesion


Direct StentingDirect Stenting

Stent Stent deploymentdeployment Balloon post Balloon post dil t tidil t tidilatationdilatation


Final resultFinal result

MidMid--shaft Left Main lesionshaft Left Main lesion

Unprotected LMCA StentingUnprotected LMCA StentingU p otected C Ste t gU p otected C Ste t g

2. Technically difficult and controversial2. Technically difficult and controversialPatients with preserved LV function and non calcified Patients with preserved LV function and non calcified di t l LM bif ti l i i l i th ti f LADdi t l LM bif ti l i i l i th ti f LADdistal LM bifurcation lesion involving the ostium of LAD distal LM bifurcation lesion involving the ostium of LAD and LCxand LCx

PCI could be considered whenPCI could be considered whensmall LCxsmall LCxsmall LCxsmall LCxelderlyelderlyhigh surgical risk (Euroscore)high surgical risk (Euroscore)g g ( )g g ( )distal coronary disease unfavorable to CABGdistal coronary disease unfavorable to CABGcomorbidity (chronic obstructive lung disease) comorbidity (chronic obstructive lung disease) emergency clinical situation: acute LM occlusionemergency clinical situation: acute LM occlusion

Left Main StentingLeft Main StentingProvisional stentingProvisional stentingProvisional stentingProvisional stenting

Distal LM stenosisDistal LM stenosis

Bifurcation Bifurcation –– «T» technique«T» techniqueqq

Bifurcation Bifurcation –– «T» technique«T» techniqueqq

FF--U angio. 13 monthsU angio. 13 months

Unprotected LMCA StentingUnprotected LMCA StentingUnprotected LMCA StentingUnprotected LMCA Stenting

33. Surgery preferred. Surgery preferred. Heavy calcified LM disease. Heavy calcified LM disease

. Reduced LV function. Reduced LV function

. Good candidate for surgery. Good candidate for surgery

with distal bifurcation lesion and reduced LVwith distal bifurcation lesion and reduced LVwith distal bifurcation lesion and reduced LV with distal bifurcation lesion and reduced LV functionfunction

with distal bifurcation lesion and occluded RCAwith distal bifurcation lesion and occluded RCAwith distal bifurcation lesion and occluded RCAwith distal bifurcation lesion and occluded RCA

with MVD suitable for CABGwith MVD suitable for CABG

Distal LM stenosis + CTO of LADDistal LM stenosis + CTO of LAD

Distal LM stenosis + CTO of LADDistal LM stenosis + CTO of LAD

Distal LM stenosis + 3VDDistal LM stenosis + 3VD

Distal LM stenosis + 3VDDistal LM stenosis + 3VD

Calcified LM stenosisCalcified LM stenosis

LM stenosis + 3VD + EF<40% LM stenosis + 3VD + EF<40%

(RCA & LC l i LAD t i )(RCA & LC l i LAD t i )(RCA & LCx occlusion, LAD stenosis)(RCA & LCx occlusion, LAD stenosis)

LM stenosis + 3VD + EF<40% LM stenosis + 3VD + EF<40%

(RCA & LC l i LAD t i )(RCA & LC l i LAD t i )(RCA & LCx occlusion, LAD stenosis)(RCA & LCx occlusion, LAD stenosis)

Distal LM stenosis Distal LM stenosis

+ dominant LCx + dominant LCx + dominant LCx + dominant LCx

+ LAD & LCx lesions+ LAD & LCx lesions

Distal LM stenosis Distal LM stenosis

+ dominant LCx + dominant LCx + dominant LCx + dominant LCx

+ LAD & LCx lesions+ LAD & LCx lesions

Left main stentingLeft main stentingLeft main stentingLeft main stenting

••Stenting can be performed with acceptable results in Stenting can be performed with acceptable results in selected patientsselected patientsselected patientsselected patients••Patient selection (clinical & angiographic Patient selection (clinical & angiographic h t i ti ) i i l d t b di d ithh t i ti ) i i l d t b di d ithcharacteristics) is crucial and must be discussed with characteristics) is crucial and must be discussed with

surgeonsurgeonC f l f llC f l f ll i d d t l t f t di d d t l t f t d••Careful followCareful follow--up is needed to evaluate safety and up is needed to evaluate safety and

efficacy of our proceduresefficacy of our procedures••Trials are needed Trials are needed

Documents

PCI for Left Main Disease - bifurc.net · PCI for Left Main Disease Jean Fajadet Cli i P t T l FClinique Pasteur, Toulouse, France Valencia , September 29 , 2007. ... What are we