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LM strategy

LM strategy. High Tech Marseille, 26 Janvier 2012. Gilles Rioufol MD PhD. Interventional cardiology dpt Cardiovascular Hospital - Lyon - France. INSERM U1060. stratification. ACS high risk T roponin + U nstable distal LM. R apid revascularization T hrombotic event

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LM strategy

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  1. LM strategy High Tech Marseille, 26 Janvier 2012 Gilles Rioufol MD PhD Interventional cardiology dpt Cardiovascular Hospital - Lyon - France INSERM U1060

  2. stratification ACS highrisk Troponin + Unstable distal LM Rapidrevascularization Thromboticevent Bifurcation management Type of stent Cx management

  3. Immediate or urgent revascularization? No pain Hemodynamicinstability? Loading dose clopidogrel Close watching– ICU P2Y12 measurement 12h later Complianceevaluation Bleedingriskevaluation Patient’schoice Technicalstrategy

  4. Thrombus management Bifurcation PCI = multiple balloons inflations = highembolizationrisk The angiogram showed a marked decrease in the thrombus burden.

  5. Technicalstrategy Medina 1.0.0 ? Medina 1.1.0 ? Cx #3.5 mm diameter– 90° takeoff – ostium free/contralateral plaque Cx ostia LM diameter # 0.678*(3.5+3) # 4.5 mm ? Stent design allowing 1.5 mm step?

  6. Soulis et al. J of Biomechanics 2006;39:742. Main vessel Side branch Unprotected LMCA IVUS-guided PCI 3 Vessel dimensions Range [0.23 - 1.42 mm] ∆D = 0.79 ± 0.36 mm 3.65 ± 0.77 mm 4.44 ± 0.84 mm 3.04 ± 0.58 mm D03 = D13 + D23 Murray’s law D0 = 0.678 x (D1 + D2)Linear law Murray CD. Proc. Natl Acad. Sci. USA, 1926 Finet G. et al. EuroIntervention 2007 Motreff P., Finet G. et al. Eurointervention 2009 4.51 mm 3.45 mm

  7. Distribution of low shear stress and localization of atherosclerosis lesion Plaque thickness (mm), n=36 Nakazawa et al. JACC 2010;55:1679

  8. LM PCI : type of stent? Park et al. CirccardiovascInterv 2009;2:167

  9. Guidelines on myocardialrevascularization ESC 2010

  10. IntraVascularUltraSound help – EBM (I) Stent underexpansion are related to stent thrombosis after SES implantation Procedural characteristics, angiographic and IVUS findings Fujii et al. JACC 2005

  11. IntraVascularUltraSound help – EBM (II) MAIN COMPARE registry DES (sirolimus) n=145 Propensy-matchedpaired-patients analysis Park et al. CirccardiovascInterv 2009;2:167

  12. Guidelines on myocardialrevascularization ESC 2010

  13. LM PCI : why IVUS helps (I)

  14. LM PCI : why IVUS helps (II) (3)Ostial LAD 8,06mm2 (1) Ref LM 16,2mm2 (2) LM stenosis 4,9mm2 LAD LM CIRCX DES 16x3.5 – kissing 3.5/3.0

  15. MLA 9,8 mm2 LM LAD LM LAD CIRCX CIRCX Postdilatation 4.5 mm DES 16x3.5 – kissing 3.5/3.0 malapposition

  16. Conclusion Proposalstrategy Thienopyridinresponse Compliance Technicalfeasability Thrombus management DES – IVUS guided length diameter apposition SB SB Provisionalstenting Final kissing

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