PCI in Left Main Coronary Bifurcation Disease -Step Mini Crush TianJin Chest Hospital Wei Wang Hantao Jiang

Case Information 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 。

Decreased diastolic function LAB：TG 5.19 TC 1.88 HDL 0.97 LDL 3.45 Case Information 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

CAG 75%Stenosis in LMd , 70%-80% stenosis inLADpm, 70% stenosis in LCXp SYNTAX SCORE 28

IVUS MLD 2.03mm MLA 4.41mm2 PB 77% IN LM MLD 1.78mm MLA 2.93mm2 PB 72% inLAD Pull back from LAD

IVUS MLD1.76mm MLA3.64mm2PB 65% in LCX

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)

PCI 3.0*29mm Firebird2 Stent deployment in LADp to middle ,after predilatation in LADm and LMd

PCI predilatation in LCXp and LADp, 3.0*13mmFirebird2 stent deployment in LCXp to LMd

PCI Inflate the baloon in LM, and crush the stent protruded into LM from LCXp

PCI accurate position of ostial LM stent

PCI 4.0*23mm Firebird2 stent deployed from LADm to the ostium of LM

PCI Rewire LCX，post dilate LADp to ostial LM and LCXp with 4.5*8mm and 3.0*12mm NC baloon separately ，final kisssing

IVUS IVUS to check stent apposition from LADm to LM

IVUS Check stent apposition from LCX to LM

COMMENT PCI One or Two Stents IVUS Pre OR Post distal LMCA bifurcation Medina 1,1,1 SYNTAX SCORE 28 CABG or PCI PCI One or Two Stents IVUS Pre OR Post

Indications for CABG vs PCI in patients suitable for both procedures 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 3-vessel disease, complex lesions, incomplete revascularization achievable with PCI, SYNTAX score >22 III A Left main (isolated or 1-vessel disease ostium/shaft) Left main (isolated or 1-vessel disease distal bifurcation) IIb B Left main plus 2- or 3-vessel disease, SYNTAX score <32 Left main plus 2- or 3-vessel disease, SYNTAX score >33 III B LAD=left anterior descending coronary artery Chinese Journal Cardiology,April 2012,Vol. 40 No. 4 17

IVUS: LM stenting Always IVUS PRE FOR intermediate lesions FOR Sizing and procedural planning To assess ostial LAD and LCX To determine when(and howmuch)to debulking POST 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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