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Antonio Colombo

ADVANCED ANGIOPLASTY 2007 London 24-26 January 2007. Established and future techniques in left main intervention. Antonio Colombo. Centro Cuore Columbus Milan, Italy S. Raffaele Hospital Milan, Italy. Nothing to disclose regarding this presentation.

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Antonio Colombo

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  1. ADVANCED ANGIOPLASTY 2007 • London 24-26 January 2007 Established and future techniques in left main intervention Antonio Colombo Centro Cuore Columbus Milan, Italy S. Raffaele Hospital Milan, Italy

  2. Nothing to disclose regarding this presentation

  3. Left main stenting with drug-eluting stents should become the standard of care in patients with this condition

  4. NYS Database CABG for Left Main Disease 1997-2000 N=16,365 No exclusions! Mortality rate (%) Death Ed Hannon, David Faxon: Personal communication to Roxana Mehran CP1131285-5

  5. Duke DatabaseCABG for Left Main Disease N=1374 Mortality (%) N= 1374 1295 1169 1039 902 748 618 personal communication Peter Berger to Roxana Mehran CP1131285-5

  6. Success is defined by an optimal angio and IVUS result

  7. Bifurcation lesion - ULM Rotablator Baseline

  8. Bifurcation lesion - ULM Result after rtb and POBA

  9. Bifurcation lesion - ULM Stents deployment

  10. Bifurcation lesion - ULM Post dilatation balloon : 3.5x20 mm 16Atm

  11. Bifurcation lesion - ULM CSA : 7.4 mm2 IVUS LCX ostial IVUS Final Result

  12. Bifurcation lesion - ULM 5 months Follow Up

  13. Bifurcation lesion - ULM Lumen Area : 2.1mm2 IVUS LCX ostial IVUS 5 months Follow Up

  14. LAD Os Cx Os IVUS Images Post Rotablator

  15. Crush technique: 3.0x33 Cypher in Cx and 3.5x18 Cypher in LAD.

  16. Final result after kissing No restenosis at FU

  17. Optimal lesion preparation IVUS guidance Optimal stent implantion V or Crush Left main distal bifurcations remain at high risk for restenosis (usually focal)

  18. Baseline characteristics Final result: according to angiography and IVUS Angiography does not override IVUS and vice versa is also true Conclusions

  19. A meta-analysis of ULM stenting with DES 823 citations retrieved from database searches 777 titles/abstracts excluded because non-relevant 46 complete articles assessed according to the selection criteria 29 articles excluded according to explicit inclusion/exclusion criteria 7 duplicate publications 4 enrolling <20 patients 8 ongoing 5 unpublished 5 using BMS only 17 studies (16 cohorts) finally included in the systematic review

  20. Rate of in-hospital death (%) Agostoni et al (2005, 58 pts) 1,7 Carriè et al (2006, 49 pts) 0,0 Chieffo et al (2005, 85 pts) 0,0 Christiansen et al (2006, 42 pts) 2,4 0,0 de Lezo et al (2004, 52 pts) KOMATE (2005, 54 pts) 1,9 Lee et al (2006, 50 pts) 2,0 Study Lozano et al (2005, 42 pts) 9,5 Migliorini et al (2006, 156 pts) 7,1 0,0 Park et al (2005, 102 pts) Price et al (2006, 50 pts) 0,0 Sheiban et al (2006, 72 pts) 2,8 Wood et al (2006, 100 pts) 2,0 Overall estimate (95%CI) 2,0 (0,9-3,2) 0 3 6 9 12 15

  21. Rate of in-hospital MI(%) Agostoni et al (2005, 58 pts) 3,5 Carriè et al (2006, 49 pts) 4,1 Chieffo et al (2005, 85 pts) 5,9 Christiansen et al (2006, 42 pts) 0,0 de Lezo et al (2004, 52 pts) 3,9 KOMATE (2005, 54 pts) 0,0 Lee et al (2006, 50 pts) Study 0,0 Lozano et al (2005, 42 pts) 0,0 Migliorini et al (2006, 156 pts) 0,6 Park et al (2005, 102 pts) 6,9 Price et al (2006, 50 pts) 8,0 Sheiban et al (2006, 72 pts) 2,6 Wood et al (2006, 100 pts) 3,0 Overall estimate (95%CI) 2,7 (1,2-4,3) 0 3 6 9 12 15

  22. Rate of mid-term MACE (%) Agostoni et al (2005, 58 pts) 15,5 8,2 Carriè et al (2006, 49 pts) Chieffo et al (2005, 85 pts) 32,7 7,1 Christiansen et al (2006, 42 pts) de Lezo et al (2004, 52 pts) 5,8 14,3 Dudek et al (2006, 28 pts) Han et al (2006, 138 pts) 10,9 Study 4,6 KOMATE (2005, 54 pts) Lee et al (2006, 50 pts) 10,6 26,2 Lozano et al (2005, 42 pts) Migliorini et al (2006, 156 pts) 23,7 25,5 Palmerini et al (2006, 94 pts) Park et al (2005, 102 pts) 8,8 54,0 Price et al (2006, 50 pts) Sheiban et al (2006, 72 pts) 9,1 19,0 Wood et al (2006, 100 pts) 16,3 (11,4-21,2) Overall estimate (95%CI) 0 15 30 45 60

  23. Rate of mid-term death (%) Agostoni et al (2005, 58 pts) 5,2 Carriè et al (2006, 49 pts) 0,0 Chieffo et al (2005, 85 pts) 2,8 Christiansen et al (2006, 42 pts) 4,8 0,0 de Lezo et al (2004, 52 pts) Han et al (2006, 138 pts) 5,1 Study KOMATE (2005, 54 pts) 1,9 Lee et al (2006, 50 pts) 4,0 Lozano et al (2005, 42 pts) 19,1 10,9 Migliorini et al (2006, 156 pts) Palmerini et al (2006, 94 pts) 13,8 0,0 Park et al (2005, 102 pts) Price et al (2006, 50 pts) 10,0 Sheiban et al (2006, 72 pts) 2,6 8,0 Wood et al (2006, 100 pts) Overall estimate (95%CI) 4,9 (2,8-7,0) 60 0 15 30 45

  24. Rate of mid-term TVR (%) Agostoni et al (2005, 58 pts) 6,9 Carriè et al (2006, 49 pts) 2,0 Chieffo et al (2005, 85 pts) 18,8 Christiansen et al (2006, 42 pts) 4,8 1,9 de Lezo et al (2004, 52 pts) Dudek et al (2006, 28 pts) 0,0 Han et al (2006, 138 pts) 7,3 Study KOMATE (2005, 54 pts) 2,3 Lee et al (2006, 50 pts) 6,3 2,4 Lozano et al (2005, 42 pts) Migliorini et al (2006, 156 pts) 12,1 2,0 Park et al (2005, 102 pts) Price et al (2006, 50 pts) 44,0 Sheiban et al (2006, 72 pts) 3,9 8,0 Wood et al (2006, 100 pts) Overall estimate (95%CI) 6,6 (3,7-9,4) 0 15 30 45 60

  25. 60% Beta=-0.012 P=0.005 Price et al 50% 40% Chieffo et al 30% MACE rate at a median of 10 months Palmerini et al Lozano et al Migliorini et al Wood et al 20% Agostoni et al Han et al Lee et al 10% Christiansen et al Carrié et al Sheiban et al Park et al KOMATE de Lezo et al 0 0 10% 20% 30% 40% 50% 60% 70% Prevalence of non-bifurcational ULM

  26. Body or Ostial ULM ( No involvement of bifurcation ) 41 pts 75 pts • 144 pts in 5 centers • 39 PES • 105 SES • 19.4% diabetics • 50% IVUS guidance • 99% procedural success 28 pts Chieffo et al submitted 2007 2 Milan, 1 Turin, 1 Rotterdam, 1 Korea

  27. Body or Ostial ULM ( No involvement of bifurcation ) 41 pts 75 pts 1 year Follow-Up Angio F-U 100 pts (70%) death : 1 pt PCI : 1 pt CABG : 1 pt 28 pts Chieffo et al submitted 2007

  28. At 2 yrs FU there where 3 additional deaths4 patients had late thrombosis?

  29. Ignorance is better than Wrong Knowledge

  30. Drug Eluting Stent Implantation Versus Bypass Surgery in Unprotected Left Stenosis: A Single Center ExperienceAlaide Chieffo, Nuccia Morici, *Francesco Maisano, Matteo Montorfano, Flavio Airoldi, Mauro Carlino, Lorenzo Arcobasso, Gloria Melzi, *Ottavio Alfieri, Antonio Colombo. Interventional Cardiology and *Cardiac Surgery Units, San Raffaele Hospital, Milan, Italy Published Circulation 2006

  31. In-HospitalOutcome

  32. One year Outcome

  33. Cause and Time of Death in DES Patients

  34. Cumulative MACCE at 1 Year Odds Ratio and Exact 95% CI PCI better CABG better

  35. Cumulative MACCE without Revascularization at 1 Year Odds Ratio and Exact 95% CI PCI better CABG better

  36. Problems: Optimal IVUS results based on comparison of lumen sizes (normal vs. diseased) not based on true IVUS vessel diameter (takes advantage of positive remodeling) Final MLD difference between IVUS and Angio guidance too small Past Studies with BMS

  37. TULIP IVUS Angio Postintervention (mm) 3.01±0.40 2.80±0.31 OPTICUS IVUS Angio Postintervention (mm) 3.02±0.49 2.91±0.41 RESIST IVUS Angio Postintervention (mm) 2.57±0.41 2.46±0.46 AVID IVUS Angio Postintervention (mm) 7.54±2.86 6.94±2.46 Post-intervention MLD

  38. 1) stent size: average diameters media to media at the distal segment of the lesion 2) post dilating balloon: average diameters media to media throughout the stented segments (different size and length balloons for long stents, always non compliant balloons able to reach at least 25 atm) 3) Optimal final result: at least 65% cross sectional area of the balloon used to post-dilate the stent or an area over 9 mm² IVUS criteria for optimal stenting Criteria based on vessel size: MEDIA TO MEDIA

  39. Initial experience with IVUS guided DES implantation according to new criteria 35 pts 3.0 ± 0.49 2.4 ± 0.47 mm Angio Ref. diam Balloon size

  40. Initial experience with IVUS guided DES implantation according to new criteria 35 pts 28±3.6atm 2.4±0.47mm 3.0±0.49 mm

  41. Left main stenting with drug-eluting stents should become the standard of care in patients with this condition

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