1.Antonio Colombo Centro Cuore Columbus and S. Raffaele Scientific Institute, Milan, Italy Madrid: 2-4 October 2013 Speaker 15 Complex Coronary Interventions PART 2 Round Table 1 Left Main Coronary Treatment

2. A case for surgery even in the era of Drug Eluting Stent 3. ESC guidelines 2010 CABG vs. PCI Left main (isolated or 1VD ,ostium/shaft) - CABG = IA, PCI = IIa B Left main (isolated or 1VD, distal bifurcation) - CABG = IA, PCI = IIb B Left main + 2VD or 3VD,SYNTAX score < 32 - CABG = IA, PCI = IIb B Left main + 2VD or 3VD,SYNTAX score 33 - CABG = IA, PCI = III B * I/IIb/III = recommendation class, A/B = level of evidence 4. Guidelines summary CABG gold standard but PCI good option in ostial/shaft disease or when SYNTAX 22 and risk of surgical complications is relatively high PCI also acceptable in high surgical risk patients with distal LM disease or when SYNTAX 32 PCI should not be performed in patients who can undergo CABG and have unfavourable anatomy (SYNTAX > 33) 5. SYNTAX 0-22 SYNTAX 23-32 SYNTAX 33 SYNTAX trial MACE subanalysis LMS and SYNTAX score CABG PCI 6. DELTA substudy ostial/midshaft vs. distal LMS Difference in MACE driven by TVR with no difference in all-cause death or composite of all-cause death and MI Distal Ostial /midshaft 7. 5 yrs. results in the LM COMPARE trial, SJ Park et al. JACC Inter 8. PCI and CABG do not work by intention to treat The most important issue is long term results In PCI success is WRONGLY defined as successful stent placement Optimal: IVUS confirmed stent placement, should be (in my view) the gold standard 9. 591 (85.8%) patients treated with DES for ULM between April 2002 and December 2010 349 (55%) patients treated using 1-stent 266 (45%) patients treated using 2-stent Exclusion criteria Acute MI, ISR, dissection and CABG 75 (28.2%) Mini-crush or T-stenting 52 (19.5%) Culotte stenting 32 (12.0%) SKS or V-stenting 51 (19.2%) Crush stenting 29 (10.9%) Provisional T, TAP-stenting 325 (93.1%) LM-LAD stenting 24 (6.9%) LM-LCx stenting 494 patients (84.0%) with angiographic follow-up 84 ostial/ body ULM lesion 14 ULM treated with 3-stent 689 patients treated with DES for ULM between April 2002 and December 2010 In Milan and New-Tokyo The overall cardiac-death, MI and MACE during the follow-up (median 24 months) occurred in 4 (5.12.5%), 2 (2.92.0%) and 31 (38.25.4%) patients respectively. Repeat-TLR occurred in 28 (34.75.3%) patients. 10. Main findings The main issue in LM disease is not LM disease but associated 3V disease In LM bifurcation lesions restenosis of the LCx is frequent but does not impact on mortality (the obsession of LCx restenosis) 11. Index procedure Baseline September 2004 12. Left Main restenosis September 2004 Final Result Cypher Mini-Crush 13. Routine follow-up, pt. asymtomatic Febr 2005 5- Month FU No Treatment 14. Left Main restenosis Febr 2005 5- Month FU No Treatment 15. 2nd FU: pt asymptomatic June 2005 8- Month After LM stent 16. June 2005 8- Month After LM stent 17. LCx restenosis June 2005 8- Month After Cypher V-Stenting Final Result 18. LCx restenosis March 2006 17- Month After first PCI No Treatment 9- Month After Second PCI 19. LCx restenosis November 2008 Baseline 41- Month After Second PCI 20. LCx restenosis November 2008 Endeavor Resolute Culotte 41- Month After Second PCI 21. LCx restenosis November 2008 Final Result 41- Month After Second PCI 22. Baseline Angiographic and Procedural Characteristics of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy (I) Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value LM+ 3VD 168 (41.4) 90 (36.9) 78 (48.1) 0.03 High SYNTAX score 144 (39.2) 88 (38.6) 56 (40.3) 0.83 Stenosis of Left circumflex >75% 176 (37.4) 71 (25.4) 105 (54.1) 0.001 Stenosis Length of Left circumflex >10mm 93 (22.1) 38 (15.3) 55 (32.2) 0.003 True-Bifurcation Medina 111,101,011 291 (61.4) 134 (47.9) 157 (80.9) 0.001 ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound 23. Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value IABP 66 (14.5) 27 (10.3) 39 (20.4) 0.003 IVUS 230 (48.5) 147 (52.5) 83 (42.8) 0.04 Rotational Atherectomy 34 (7.5) 23 (8.4) 11 (6.0) 0.37 Total Stent Length 25.9712.05 22.477.19 30.8515.35 0.001 Baseline Angiographic and Procedural Characteristics of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy (II) ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound 24. Outcome at 3 Years of Patients Treated for UDLM According to Original 1-Stent Strategy or 2-Stent Strategy Patients: n (%) All patients (n=474) 1-Stent Strategy (n=280) 2-Stent Strategy (n=194) P value Angiographic follow-up 405(89.8) 234 (89.3) 171 (90.5) 0.48 All-death 38 (8.5) 24 (9.0) 14 (7.7) 0.74 Cardiac-death 21 (4.5) 14 (5.1) 7 (3.6) 0.37 Non Cardiac death 17 (3.6) 10 (3.6) 7 (3.6) 0.49 In-stent restenosis 85 (17.9) 35 (12.5) 50 (25.8) 0.01 In-stent restenosis at the ostial LCX 41 (8.6%) 14 (5.0%) 27 (13.9%) 0.001 Myocardial Infarction 6 (1.3) 3 (1.1) 3 (1.6) 0.10 ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound 25. IVUS evaluation mandatory every time 2 stents are implanted: If IVUS cath does not cross the stent perform a better postdilatation 26. Before After After appropriate sizing 27. Final 28. Distal Left Main Bifurcation in a Patient with Low EF 87 Y old Gentleman High 160 cm Weight 59 Kg Effort Angina Class III Hypertension No Diabetes Creatinine 2.0 mg%-ml No prior PCI No associated medical condition Positive Exsercise Test at Low Level EF 25% Mitral Insufficent grade III 45 mmHg Pulmonary Pressure 67198/12 HSR History 29. Distal Left Main Bifurcation in a Patient with Low EF Baseline IABP in place 67198/12 HSR 30. Distal Left Main Bifurcation in a Patient with Low EF Rotablator 1.5 mm BURR 67198/12 HSR 31. Distal Left Main Bifurcation in a Patient with Low EF Following Rotablator toward LCX 67198/12 HSR 32. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Following Rotablator toward LAD 33. Distal Left Main Bifurcation in a Patient with Low EF 3.0mm NC Balloon to LAD 67198/12 HSR 2.5 mm NC Balloon to LCX 34. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Kissing Balloon 3.0mm NC Balloon to LAD 2.5 mm NC Balloon to LCX Stenting LAD 3.0 - 14 mm 35. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Post Dilatation Prox-LAD Stent with 3.0 mm NC Balloon Following LAD Post Dilatation 36. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Struts open toward LCX 37. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR 2.5 8 mm to LCX With TAP Technique 38. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Stenting LCX Kissing Balloon 39. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSR Final Result 40. Distal Left Main Bifurcation in a Patient with Low EF 67198/12 HSRFinal Result 41. Baseline 27287/09CCC 42. Baseline 27287/09CCC 43. Baseline 27287/09CCC After stent Resolute 2.5x12mm 44. 27287/09CCCAfter stent 45. 27287/09CCC Predilation of LAD with wire protection of 2 Septals, Intermediate and Circumflex 46. 27287/09CCCResolute 3.5x30mm 47. 27287/09CCC Kissing Inflation after stenting of LAD towards LM LAD 3.5mm balloon LCX 2.5mm balloon Ramus 2.0mm balloon 48. 27287/09CCC After Kissing Inflation and LAD stenting 49. 27287/09CCC After Kissing Inflation intermediate Distal LM 50. 27287/09CCC T stenting towards Cx and Intermediate with 4 mm Balloon inflated in LAD 51. 27287/09CCC LAD: 4.0mm balloon LCX : 2.5x30mm Resolute Ramus : 2.5x30mm Resolute 52. 27287/09CCC LAD: 4.0mm Quantum -23 Atm LCX : 2.5mm Quantum 25Atm Ramus : 2.5mm Quantum 25Atm High pressure NC Balloons postdilation 53. 27287/09CCC Intermediate LCX Distal LM 54. 27287/09CCC Distal LM Intermediat e 55. 27287/09CCC Final Result 56. 27287/09CC Final Result 57. 27287/09CC Final Result 58. 1. Occlusion of the LAD or of the RCA which cannot be opened by PCI and with viable myocardium. Chronic occlusion of the RCA and sometimes even of the LAD can left untreated in elderly people with reduced physical activity. 2. Complex and calcific distal left main bifurcation and the PCI operator does not feel confident to treat or she/he does not expect to obtain a good final result 3. Long diffuse disease in the proximal LAD (needs a stent longer than 30-35 mm) in a patient with diabetes mellitus 4. A patient who has or may have problems with dual antiplatelet therapy Conditions were CABG may be a better choice compared to PCI in patients with Left Main Stenosis: