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6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST

6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST. Kissing in simple strategy ? Why and how I kiss Y. Louvard, ICPS, Massy France. A long experience of kissing. 1997 P value 82 - 43.3 <0.001 96.3 NS 10.9 0.002 10.9 0.014

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6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST

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  1. 6th European Bifurcation Club 22-23 October 2010 - BUDAPEST Kissing in simple strategy ?Why and how I kiss Y. Louvard, ICPS, Massy France

  2. A long experience of kissing 1997 P value 82 - 43.3 <0.001 96.3 NS 10.9 0.002 10.9 0.014 0 NS 2.4 NS 1.2 NS 0 NS 14.5 <0.001 1996 Patients 79 Final Kissing balloon (%) 13.9 Angiographic success (%) 96.2 7 months TVR (%) 36.7 - PTCA (%) 30.4 - CABG (%) 6.3 7 months Death (%) 5.0 7 months Non Q MI (%) 2.6 7 months Q MI (%) 1.2 7 months MACE (%) 45.6 Lefèvre et al. TCT Washington 1998

  3. Kissing is part of a strategy • One layer of DES when and where it is useful - no overlap, no protrusion - good expansion - SB only in case of poor result after balloon MB first: provisional SB stenting strategy • Try to restore the original anatomy and function of the bifurcation

  4. Excess of metal : endothelisation ? Finn et al. Circulation; 112:270-8

  5. Application of fluid dynamics analysis: Macroscopic flow perturbations at stented bifurcation site A A B B B Protrusion: flow perturbations 12 Physiological flow through a bifurcation model with palmaz stent A stagnation zone (A) appear if the stent does not conform to the artery. The stent implantation in a daughter branch induces recirculation zones in the healthy artery branch (B) due to the protruding part of the stent. Fabregues, 1998, J. of Biomech.31

  6. Protrusion: flow perturbations Delplano et al, EBC 2007

  7. IVUS data for non-LM bifurcation lesions (IVUS in both branches) Default of MB stent expansion when stenting SB first: crush R. Costa et al. JACC 2005; 46: 599-605

  8. Balloon or stent for the SB ? Postprocedural MLD of the side branch Athappan, J Cardiovasc Med 11:103–110 Q 2010

  9. Balloon or stent for the SB ? Follow-up MLD of the side branch Athappan, J Cardiovasc Med 11:103–110 Q 2010

  10. Kissing is part of a strategy One layer of DES when and where it is useful - no overlap, no protrusion - good expansion - SB only in case of poor result after balloon MB first: provisional SB stenting strategy Try to restore the original anatomy and function of the bifurcation

  11. D2 D2 D1 D1 D3 D3 Bifurcation branching laws Murray’s law D13*= D23* + D33* Finet’s law D1 = 0.67(D2 + D3) Self replicating * 2.3 HK law From Koo, EBC, 2008

  12. / Flow Myocardial mass / Length / Diameter Structure-functionscaling laws of vascular trees Kassab, EBC 2009

  13. Hemodynamic changes after MB stenting and subsequent SB balloon angioplasty Changes in time-averaged wall shear stress introduced by bifurcation stenting Williams J Appl Physiol (May 27, 2010)

  14. Which technique ? ? From Gastaldi. Biomech Model Mechanobiol (2010) 9:551–561

  15. * Optimal Provisional SB Stenting * D1 D1= (D2 + D3) 2/3 POT* D3 D2 * Successfull POT vs no POT *O. Darremont, publication very very soon

  16. Why kissing after simple stategy ? • To correct a poor result in SB (but QCA / FFR discrepancy): - TIMI flow < 3, EKG, Pain … - carena / plaque shift - previous stenosis - to prepare a SB stenting • When SB angiographic result / flow are good ?: to remove the jail strut (possible SB stenting: > 2 mm) • Always (?): to relocate the flow divider

  17. Stable angina • Male, 65 yo • Stented on prox. LAD • No image • No diagonal protection, no kissing on the report • Stable angina

  18. Stress MRI (Dipyridamole, 1st pass myocardial perfusion)

  19. Rotablator: 1.25 mm burr

  20. Result

  21. Kissing balloon clinical results

  22. Nordic – Baltic III (6 m) n=239 n=238 * Non-procedure related Nordic III, EBC 2009

  23. COBIS Registry Independent Risk Factors for MACE and TLR Gwon Circ J 2010 Sept 28

  24. No! No! Too brutal !

  25. Kissing With NC Balloons Don’t kiss too big (non-compliant balloons) Bifurcation lesions (n) 100 FKS success (%) 100 FKS success without SB opening (%) 97 Metal projection in SB (%) 89 Need for SB stenting (%) 7 In-hospital MACE (%) 0 Hovasse et al. AHA 2009 Kinoshita, EBC 2009

  26. Optimal FKB in the bench Kiss precisely (short balloons) Minimal overlaping Long overlaping Murasato et al. PCR 2010

  27. 20 seconds is not enough ! Optimal FKB in the bench 16 8.5 14 8.0 12 7.5 10 Stent Recoil % 7.0 8 Cross-Sectional Area mm2 6.5 6 6.0 4 2 5.5 0 5.0 20s×1 20s×2 20s×3 20sec×1 20sec×2 20sec×3 Hikichi et al. EBC 2009

  28. Optimal FKB in the bench Kiss subtle ! (MV inflation first) Simultaneous MV balloon First SB balloon First CSA (mm2) IVUS Main vessel stent 10 8 6 Dist. Dist. Dist. Prox. Prox. Prox. Carina Carina Carina 4 2 0 * p<0.05 vs. Simultaneous, † p<0.02 vs. Simultaneous Sung-Jin Oh et al. PCR 2010

  29. After a good kiss you may have a good surprise !

  30. Nordic-Baltic Bifurcation Study III (6 m) (Re)stenosis: Ostial Side Branch % 15.4% 7.9% p=0.039 Binary Restenosis: ≥50% diameter stenosis at follow-up

  31. Nordic-Baltic Bifurcation Study III (6 m) True Bifurcation Subgroup Medina 1,0,1 - 0,1,1 – 1,1,1

  32. "Baiser de l'Hôtel de Ville » - 1950 Robert Doisneau

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