Hungary Presents: Use of Imaging for Left Main PCI Optimization István F. Édes MD PhD Semmelweis University Heart and Vascular Center Budapest, Hungary edes789@gmail.com

Disclosure Statement of Financial Interest I, István F. Édes DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Left Main (LM) disease Significant LM disease significantly impacts coronary artery disease (CAD) prognosis LM revascularization is a difficult decision: LM size and disease severity Complexity of the LM lesion Concomitant CAD and other disease Clinical manifestation of LM stenoses

Left Main treatment LM treatment in most cases still remains a prime target for the surgeon PCI CABG LM Syntax score <22 I B LM Syntax score 23-32 IIa B 3VD, LM Syntax score 23-32 III B I A 3VD, LM Syntax score >32 This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 3

Left Main treatment The more severe the issue the less PCI comes into question (Syntax Trial) But… Emergency cases (ACS) Third generation DES Single stent based prefered strategies Better patient selection Better DAPT (prasugel & ticagrelor) Availablity of routine intravascular imaging

Intracoronary imaging - guidelines ACC - 2011 Class IIa IVUS is reasonable for the assessment of angiographically indeterminant left main CAD. (Level of Evidence: B) IVUS is reasonable to determine the mechanism of stent restenosis (Level of Evidence: C) Class IIb – IVUS may be reasonable for the assessment of non–left main coronary arteries with angiographically intermediate coronary stenoses (50% to 70% diameter stenosis). (Level of Evidence: B) IVUS may be considered for guidance of coronary stent implantation, particularly in cases of left main coronary artery stenting. (Level of Evidence: B) IVUS may be reasonable to determine the mechanism of stent thrombosis (Level of Evidence: C) ESC - 2015 IVUS / OCT In case of stent restenosis and thrombosis– Class IIa, LoE: C LM PCI with IVUS initally grants better short term results IVUS guided PCI decreased stent thrombosis and restenosis rates

Invasive imaging pros and cons Intravasular Ultrasound 20-60 MHz frequency Ultrasound technique ~100-150 µm resolution 6-7 mm penetration Real-time imaging Calcification NURD Spasm Optical Cohoerence Tomography 300 nm range Light based technique ~10-15 µm resolution (cellular level) 2-3 mm penetration Penetration through calcification Non real-time Contrast flush need LM imaging Preferred modality: IVUS! 6

When and how to use IVUS in the LM? Recommendation LM PCI planned To assess severity: IVUS alone may not be optimal, as functional testing and/or ischaemia induction may be needed. But, aim for a target MLA: <6 mm2 Pre-PCI: Evaluate LM size, calcification, fibroelastic components, bifurcation (bi-directional IVUS) and ostial status. Post-PCI: Evaluate stent edges, apposition, need for post-dilation, bifurcation geometry. Determine pre-PCI IVUS characteristics IVUS no-cross Predilate Bifurcation disease Non-bif. disease IVUS again IVUS both ways Optimally prepare LM lesion IVUS both ways, optimize stent as needed Apply stents (one preferred)

Pre-PCI imaging: more tips&tricks Ostial lesion? Assess amount of calcium, fibrous tissue Shaft lesion? Carefully verify if bifurcation and ostium are truly unaffected Bifurcation lesion? Focus on the degree of bi-directional disease (plaque burden)

Post-PCI imaging: more tips&tricks Ostial stent? Assess prolapse of stent into the aorta, create a cone as needed Shaft stent only? Very carefully assess if bifurcation and ostium are truly uncovered Bifurcation stents? Concentrate on the neo-carina

Thank you for your attention!