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COMPLEX PCI 2024

State-of-the-Art Left Main PCI

Duk-Woo Park Asan Medical Center, Republic of Korea At the 9th COMPLEX PCI 2024 conference, Dr. Duk-Woo Park from Asan Medical Center, Seoul, delivered a thought-provoking plenary lecture on “State-of-the-Art Left Main PCI: Current Evidence and What Are the Next?”. His presentation offered a meticulous exploration of the latest advancements in managing left main coronary artery disease (LMCAD), combining evidence-based practices, cutting-edge technologies, and a patient-centered approach. Dr. Park emphasized the transformative role of multidisciplinary Heart Teams in guiding treatment decisions for LMCAD. Highlighting updates from the 2024 European Society of Cardiology (ESC) guidelines, he pointed out the growing reliance on randomized controlled trials (RCTs), which have shaped current clinical approaches. The nuanced interplay between patient-specific factors and anatomical complexity underscores the importance of collaborative decision-making when choosing between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Intracoronary imaging and physiological assessments took center stage as Dr. Park outlined their critical role in procedural success. Tools like intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve (FFR) are now indispensable in addressing lesion severity, ensuring precise stent placement, and optimizing outcomes. Recent RCTs such as RENOVATE-COMPLEX and OCTIVUS have consistently demonstrated improved outcomes with imaging-guided PCI, reducing target vessel failure and major adverse cardiac events. Dr. Park shared advanced criteria for stent optimization, including minimum stent area thresholds for left main arteries, developed at Asan Medical Center. For example, achieving an MSA of ≥8 mm² for the proximal left main is a key determinant of long-term success. Dr. Park introduced emerging stent technologies, including the DynamX bioadaptive stent, and discussed novel techniques like DK-CRUSH and TAP for managing bifurcation lesions. Studies such as INFINITY-SWEDEHEART and DCB-BIF highlight the benefits of these innovations, from enhanced vessel function to reduced target lesion failure rates. Physiology-guided approaches, such as FFR, address the "visual-functional mismatch" often seen in left main lesions, ensuring interventions are limited to functionally significant stenoses. Dr. Park discussed ongoing trials, including the FATE-MAIN study, which is poised to refine these strategies further. In addition, he outlined a tiered decision-making framework that incorporates imaging and physiology to assess intermediate lesions, integrating anatomical and functional data for precise stratification. Dr. Park explored emerging tools like artificial intelligence (AI) and predictive algorithms that promise to revolutionize imaging-guided PCI by automating risk assessment and stent optimization. He also touched on evolving antiplatelet regimens, referencing findings from the TAILORED-CHIP trial, which balance thrombotic and bleeding risks through personalized therapy. In conclusion, Dr. Park underscored the importance of collaboration, technological innovation, and adherence to evidence-based protocols in left main PCI. He expressed optimism about the growing capabilities of PCI techniques, which are now achieving outcomes comparable to CABG in complex cases. His lecture not only illuminated the latest advancements but also provided a forward-looking framework for interventional cardiologists navigating the complexities of LMCAD. Opening & Complex PCI Workshop 1: Left Main & Bifurcation Thursday, November 28, 1:00 PM ~ 2:15 PM Main Arena Check The Session

December 27, 2024 2730

COMPLEX PCI 2024

Left Main and Multi-vessel Disease: Updated Treatment Concept

Seung-Jung Park Asan Medical Center, Republic of Korea ‘Left Main and Multi-vessel Disease: Updated Treatment Concept’ Seung-Jung Park, MD stresses that left main (LM) disease is no longer surgical disease. Until now, LM disease was considered to require surgical revascularization. However, recent clinical trials such as SYNTAX, PRECOMBAT, EXCEL, NOBLE and meta-analysis have led to changes in the recent ESC and ACC/AHA guidelines for LM disease revascularization. 2024 ESC guidelines for revascularization of LM disease categorize LM disease and LM disease with multivessel disease into categories based on SYNTAX score: low complexity is classified as Ia, intermediate as IIa, and for LM disease with multivessel disease, PCI is indicated as IIb if surgical risk is high. 2021 ACC/AHA guidelines classified LM disease revascularization as IIa for low anatomic complexity. However, the global guidelines do not take into account the operator's experience and technical considerations. For example, the left main artery is a large vessel with a proximal lesion and a short lesion length, making it suitable for PCI, and contemporary PCI is physiology- and image-guided PCI, so the global guidelines should reflect this, Dr. Park pointed. Current Asan Medical Center practice for Left Main Disease There have also been changes in the ESC guidelines for multivessel disease. 2024 ESC multivessel disease revascularization guideline categorize multivessel disease with diabetes and without diabetes. Even in patients with diabetes, PCI is IIa if the surgical risk is high. And in the case of multivessel disease without diabetes, it is almost always Ia. And in the multivessel disease guideline, PCI is no longer classified as III. Current Asan Medical Center practice for Left Main Disease PCI Favour; All ischemic lesions, favourable anatomy for PCI (RVD > 2.5mm, and/or Lesion length < 50mm) CABG Favour; Low EF (< 40%), Diabetic, 3 vessel disease, unfavourable anatomy for PCI Majority of multi-vessel disease, 1 or 2 major vessel PCI with optical medical therapy would be enough. Dr. Park concluded his lecture by saying that randomized studies are needed to confirm the results because it is not known which outcome is better, contemporary PCI or CABG, in patients with multivessel disease with ischemic cardiomyopathy and multivessel disease with diabetes. Live Case 1: Left Main & Multi-vessel Diseases Friday, November 29, 9:00 AM ~ 10:50 AM Main Arena Check The Session

December 20, 2024 2742

COMPLEX PCI 2024

Predicting Side Branch Occlusion in Left Main Bifurcation PCI : The LM V-RESOLVE Score

Kefei Dou Fuwai Hospital, China Managing left main bifurcation lesions has always been one of the most complex challenges in interventional cardiology. These lesions, which account for 5-7% of coronary cases and often involve the distal bifurcation, are associated with high mortality rates. Despite significant advances in treatment strategies, predicting and preventing side branch (SB) occlusion during left main (LM) percutaneous coronary intervention (PCI) remains a pivotal goal. The LM V-RESOLVE score is a new, angiographic-based scoring system developed to predict the risk of SB occlusion in LM bifurcation PCI. It builds on previous versions of the RESOLVE score series, which have been widely recognized for their utility in assessing bifurcation lesion risk. However, the earlier RESOLVE models were limited in their application to LM bifurcations, as less than 5% of the initial development cohorts included these lesion types. The LM V-RESOLVE score was specifically designed to address these gaps, incorporating anatomical differences unique to LM bifurcations. The study behind the LM V-RESOLVE score analyzed a cohort of 855 patients who underwent LM bifurcation PCI with a provisional stenting strategy. After extensive data collection and regression modeling, three key angiographic parameters were identified as predictors of SB occlusion: main vessel (MV) plaque distribution, MV/SB diameter ratio, and SB baseline stenosis. Each factor contributes to the score, with higher values reflecting greater risk. For example, a stenosis rate of 70-90% in the SB adds three points to the score, while a stenosis greater than 90% adds seven points. The LM V-RESOLVE score was validated both internally and externally, showing excellent predictive accuracy with a C-statistic of 0.83. It successfully stratifies lesions into low-risk (score

December 13, 2024 1740

AP VALVES & SH 2024

Beyond COAPT: Shaping the Future of Functional MR Treatment

Takashi Matsumoto Shonan Kamakura General Hospital, Japan Takashi Matsumoto, MD stressed the benefit of transcatheter edge-to-edge mitral valve repair (TEER) for severe secondary mitral regurgitation (MR), regardless of the acute or chronic disease. The multicenter, randomized, controlled, parallel-group, open-label trial, COAPT (Transcatheter Mitral-Valve Repair in Patients with Heart Failure) trial demonstrated that transcatheter mitral valve repair resulted in lower rates of hospitalization for heart failure (HF) and all-cause mortality within 24 months of follow-up compared with medical therapy alone in patients with moderate to severe or severe secondary MR who remained symptomatic despite maximum guideline-directed medical therapy. Furthermore, this outcome benefit was also showed at 5 years of follow-up. However, the Mitra FR trial, similar with the COAPT trial that confirmed the effect of TEER on MR, did not show a significant reduction in clinical events. There are several reasons for this: differences in the severity of MR and LV remodeling between the two trials, and guideline directed medical therapy was not optimized before procedure and the quality of procedure was not good in Mitra FR trial. Nonetheless, in the landmark analysis of the Mitra FR trial analyzing patients who survived for 1 year without hospitalization for HF, the primary end point was the cumulative number of HF hospitalization at 1 year, and although it was not statistically significant, a clear reduction in the incidence of HF hospitalizations was observed in the device group. And COAPT post-approval study, a prospective, single-arm, observational study, enrolled 5,000 patients in United States, comparing COAPT like patients with Mitra like patients. In both groups, there was a similar and durable reduction of MR and a significant improvement in quality of life at 1year. He presented sub-analysis of EXPANDed Study presented at the New York Valve conference. It evaluated clinical events after MitraClip in moderate or severe MR. In both groups, there was a significant reduction in MR severity, LV reverse remodeling, symptom improvement and significant reduction in HF hospitalization. He emphasized the importance of TEER by presenting a case summary showing how to treat MR in acute decompensated heart failure with acute MR. Although it is still difficult to establish the indication and timing of urgent TEER, he concluded that TEER is a very strong treatment option for this dynamic acute functional MR and can immediately reduce MR with a very high safety profile. Live Case & Lecture 6: Mitral TEER Friday, August 09, 2:00 PM ~ 3:40 PM Main Arena, Vista Hall 1, B2 Check The Session

September 13, 2024 3170

AP VALVES & SH 2024

TAVR in Asia: Optimal TAVR Choice for Asian Patients with Small Annulus, Vessels, and Body Size

Duk-Woo Park Asan Medical Center, Republic of Korea At the recent AP VALVES & SH 2024 conference, Dr. Duk-Woo Park from the Asan Medical Center in Seoul highlighted critical considerations for Transcatheter Aortic Valve Replacement (TAVR) in Asian populations, particularly focusing on patients with smaller annuli, vessels, and body sizes. As TAVR becomes increasingly adopted across Asia, the unique anatomical challenges posed by these smaller dimensions demand careful selection of prosthetic valves to optimize patient outcomes. One of the key concerns discussed was the prevalence of small aortic annuli in the Asian population, which occurs in approximately 40% of cases. This anatomical feature is associated with a higher risk of prosthesis-patient mismatch (PPM), where the implanted valve is too small relative to the patient’s body size. This mismatch can lead to increased mechanical stress on the valve leaflets, accelerating structural valve degeneration and reducing long-term durability—a concern particularly pertinent given the growing emphasis on valve longevity in the region. The session also underscored the racial disparities in TAVR outcomes, with Asian patients showing a higher incidence of severe PPM compared to their Western counterparts. This difference emphasizes the need for tailored approaches when treating Asian patients. Dr. Park noted that while newer generation valves have improved hemodynamic performance, ensuring an optimal fit remains challenging, particularly for high-risk patients and younger, more active individuals. Further insights were provided from the SMART trial, which compared self-expanding valves (SEV) and balloon-expandable valves (BEV) in patients with small aortic annuli. The trial, one of the largest and most rigorous to date, revealed that SEVs offered superior valve performance, including a 32.2% lower incidence of bioprosthetic valve dysfunction and a 5.3% reduction in severe PPM. These findings suggest that SEVs may be particularly advantageous for Asian patients, though the direct applicability of the trial’s results to this population remains a subject of ongoing debate. In conclusion, while advancements in TAVR technology are promising, the conference highlighted the necessity of further research and validation to ensure these innovations translate into improved outcomes for Asian patients with small annuli and other unique anatomical features. Keynote Lectures on TAVR 2024 Friday, August 09, 1:00 PM ~ 2:00 PM Main Arena, Vista Hall 1, B2 Check The Session

September 06, 2024 2645

AP VALVES & SH 2024

15 Years' Journey of AMC TAVR

Seung-Jung Park Asan Medical Center, Republic of Korea At AP VALVE & SH 2024 conference, Seung-Jung Park, MD (Asan Medical Center, Korea) marked the 15th year anniversary of pioneering Transcatheter Aortic Valve Replacement (TAVR) at AMC. Over this period, AMC has evolved from its initial procedures to becoming a leader in the field, consistently improving outcomes and expanding the range of patients who can benefit from TAVR. Evolution of TAVR Guidelines and Clinical Practice Since the pivotal 2010 PARTNER IB trial, TAVR has gained acceptance as a preferred treatment for patients with severe aortic stenosis, particularly those at high surgical risk. Recent trials, including the SMART trial, have further demonstrated TAVR's benefits in younger, lower-risk populations. The meta-analysis of low-risk TAVR trials involving over 2,000 patients shows that TAVR offers superior one-year mortality rates and cardiovascular outcomes compared to Surgical Aortic Valve Replacement (SAVR). The 2020 ACC/AHA guidelines recommend TAVR as the first-line treatment for patients over 65 years old. While the ESC guidelines suggest TAVR primarily for patients over 75, with individualized assessments for those younger. However, real-world data shows a trend toward using TAVR in younger patients, with 78% of patients under 65 receiving TAVR in 2021-2022. This shift reflects a growing preference for tissue valves over mechanical ones, driven by TAVR's minimally invasive nature and favorable outcomes. AMC's TAVR Success: The Role of Minimalist Approaches and CT Algorithms AMC has now performed over 2,000 TAVR procedures, with a current rate of 300 cases annually. The center boasts a procedural success rate of 99.7%, low complication rates, and excellent one-year outcomes, including an all-cause mortality rate of 7.2% and a disabling stroke rate of less than 1%. This success is attributed to AMC’s heart team collaboration, a minimalist approach to anesthesia and patient care, and the precision of the AMC CT algorithm for device selection. The AMC CT algorithm is a cornerstone of this success, allowing for meticulous pre-TAVR planning. By analyzing factors such as vascular access, aortic annulus size, calcium distribution, and coronary height, the team at AMC ensures optimal device sizing and placement. This approach has led to low rates of paravalvular leak (PVL) and permanent pacemaker implantation, particularly with the use of balloon-expandable devices, which are preferred for their strong radial force and predictable outcomes. AMC continues to adapt its techniques to address complex cases, such as those involving bicuspid aortic valve stenosis, which typically involves higher calcium burdens and more challenging anatomies. In these cases, AMC has successfully applied its refined approaches, resulting in procedural outcomes comparable to those in tricuspid valve cases. In-depth Analysis of the SMART Trial and its Implications on TAVR Practices During the discussion of the SMART trial, particular focus was given to the management of patients with small aortic annuli (less than 430 mm²). The trial compared outcomes between self-expanding and balloon-expandable valves, with the latter using primarily 23mm devices. While both groups had similar clinical profiles, notable differences in procedural characteristics emerged. However, the device success rate was slightly lower compared to self-expanding valves. At AMC, where approximately 40% of patients fit the SMART trial criteria, data showed a high procedural success rate and a significantly lower incidence of paravalvular leak (PVL) compared to the SMART trial. This discrepancy highlights the importance of meticulous device selection and sizing, particularly in patients with small annuli. AMC’s approach, which carefully considers factors like annulus size and calcium load, has proven effective in optimizing outcomes. The differences between AMC’s outcomes and those of the SMART trial underscore the critical role of pre-TAVR planning using CT analysis. The SMART trial's use of relatively undersized devices without adequate consideration of calcium levels likely contributed to higher PVL rates. In contrast, AMC’s tailored approach, guided by detailed MDCT analysis, emphasizes the importance of precise device sizing to prevent complications. Opening, Live Case & Lecture 1: TAVR Thursday, August 08, 1:00 PM ~ 2:20 PM Main Arena, Vista Hall 1, B2 Check The Session

August 30, 2024 2540

AP VALVES & SH 2024

TAVR for Bicuspid AV: What's Different?

Jung-Min Ahn Asan Medical Center, Republic of Korea At the AP VALVES & STRUCTURAL HEART 2024 conference, Professor Jung-Min Ahn from Asan Medical Center delivered important findings on the challenges and outcomes of Transcatheter Aortic Valve Replacement (TAVR) in bicuspid aortic valve (BAV) patients. Despite the anatomical complexities of BAV, the data from Asan Medical Center suggest that TAVR can be performed as safely and effectively as in tricuspid aortic valve (TAV) patients, albeit with some unique procedural considerations. Between 2016 and 2023, Asan Medical Center conducted TAVR on approximately 1,000 patients using the Sapien 3 valve system, with 124 of these patients having BAV (Figure 1). They found that BAV patients were generally younger (mean age 77), predominantly male, and had fewer comorbidities compared to those with TAV. Echocardiographic findings indicated more severe aortic valve stenosis in BAV patients, with higher transaortic pressure gradients and more significant calcification, as evidenced by higher calcium volumes (Figure 2). Figure 1 Figure 2 Procedurally, BAV cases required larger transcatheter heart valves (THVs) and more frequent pre- and post-dilation. Notably, in BAV patients with heavy calcification, the strategy leaned toward less valve oversizing to reduce procedural risks (Figure 3). While the rates of pacemaker implantation and paravalvular leak were slightly higher in BAV patients, these differences were not statistically significant. Long-term outcomes showed no significant differences in mortality or stroke rates between BAV and TAV patients up to two years after the procedure (Figure 4, 5). Figure 3 Figure 4 Figure 5 Professor Ahn emphasized the need for developing specific criteria, similar to the Echo-Score used in rheumatic mitral stenosis, to better identify BAV patients who are ideal candidates for TAVR. This could further enhance procedural success and patient outcomes in this complex patient group. Live Case & Lecture 2: Bicuspid, Mitral TEER Thursday, August 08, 2:30 PM ~ 4:10 PM Main Arena, Vista Hall 1, B2 Check The Session

August 30, 2024 2046

TCTAP 2024

FFR and iFR: Where Do We Stand Today?

Nico Pijls Catharina Hospital, Netherlands Reassessment of Coronary Artery Disease Diagnostics: FFR Reigns Supreme In the evolving landscape of cardiology, the debate over the most reliable method for assessing coronary artery disease has reached a crucial juncture. Fractional Flow Reserve (FFR) and Instantaneous Wave-free Ratio (iFR) have both been subjects of intense scrutiny and discussion. However, recent insights, especially new recommendations from leading cardiology journals and associations, are reaffirming FFR as the gold standard for assessing coronary artery disease. Understanding FFR and iFR FFR is an index that measures the maximum achievable blood flow in the presence of a coronary stenosis compared to normal maximum flow. The underlying principles of FFR are rooted in sound physiology. It evaluates the functional capacity of a patient's heart under maximum vasodilation, correlating to exercise tolerance. This method has significantly influenced decision-making in catheterization labs, aiding in precise revascularization strategies and improving patient outcomes. However, FFR measurement necessitates a pharmacological hyperemic stimulus, typically involving adenosine or ATP infusion. Although these agents have transient side effects, the benefits of accurate measurement outweigh the minor inconveniences. In contrast, iFR emerged as a simpler alternative to FFR. Proposed by Davies et al., iFR measures the resting Pd/Pa ratio during a specific part of diastole, eliminating the need for a hyperemic stimulus. Initial enthusiasm for iFR was bolstered by two large randomized controlled trials (DEFINE-FLAIR and SWEDE-HEART), which suggested non-inferiority of iFR compared to FFR. Critical Analysis of iFR Despite the initial optimism, several concerns about iFR have come to light. The concept of a “wave-free period” during diastole lacks a solid physiological basis, and predicting hyperemic gradients from resting gradients has proven unreliable. Furthermore, serious design and interpretation issues in the DEFINE-FLAIR and SWEDE-HEART studies have raised questions about their validity. Notably, these studies involved low-risk populations, with a significant proportion of patients not undergoing PCI and many stents placed without physiological measurements. Biases in the study designs were particularly problematic. For example, almost 50% of stents were placed based on visual lesion severity rather than physiological measurement. Many false-negative iFR results were excluded from the analysis, skewing the data to appear more favorable. This bias went largely unrecognized by investigators, leading journals, and guideline committees. Long-term follow-ups revealed troubling outcomes. Mortality rates in the iFR-guided groups were significantly higher than those in FFR-guided groups, a disparity that increased over time. These findings have prompted a reassessment of iFR's reliability, especially in high-stakes clinical decisions. New Recommendations In response to these revelations, the Journal of the American College of Cardiology (JACC) and the European Heart Journal (EHJ) now recommend FFR as the preferred method for assessing proximal lesions in large coronary arteries. Upcoming guidelines are expected to reflect this preference, emphasizing FFR-guided revascularization as the standard for intracoronary pressure measurement. The cardiology community's initial enthusiasm for iFR and other non-hyperemic pressure ratios has been tempered by emerging evidence of their limitations. The biases and higher mortality rates observed in key studies underscore the necessity of relying on methods with a robust physiological basis. As such, FFR remains the gold standard, ensuring precise diagnostics and optimal patient outcomes in coronary artery disease management. Hot Topics Coronary Physiology: New Insights Friday, April 26, 3:30 PM ~ 5:44 PM Presentation Room 2, Level 1 Check The Session

June 19, 2024 2939

TCTAP 2024

Who Will Treat the Most Complex Patients? No Success Goes Unpunished.

Spencer B. King III Emory Healthcare, USA During TCTAP 2024, live cases, and lecture 6, the discussion revolved around the treatment of the most complex patient cases. Spencer B. King, MD (Emory University School of Medicine, Atlanta, GA, USA) shared insights into the evolving role of percutaneous coronary intervention (PCI) compared to surgery in such cases. In his introductory remarks, King emphasized the shifting landscape of PCI being increasingly favored over surgery, particularly in treating left main (LM) shaft disease. Significant contributions by Seung-Jung Park, MD (Asan Medical Center, Seoul, Korea) were highlighted in this paradigm shift. Previously, interventionists would often opt for surgery when confronted with challenging cases. However, King noted a trend toward choosing PCI, citing highly sophisticated PCI skills as a driving factor. An illustrative case discussed was that of an 85-year-old male patient with a history of acute coronary syndrome (ACS), recurrent chest pain, and heart failure (Figure 1). The patient presented with multiple risk factors including diabetes, chronic renal failure, cerebrovascular accident, peripheral artery disease, and severe chronic obstructive pulmonary disease. The electrocardiogram confirmed LM disease consistent with ACS. Figure 1. One most complex patient case Initial coronary angiography revealed LM plus triple-vessel disease with complex lesions, including LM trifurcation disease and heavily calcified, diffuse long left anterior descending artery disease, alongside total occlusion of the proximal right coronary artery. Given the patient's profile, both coronary artery bypass surgery (CABG) and PCI were considered. However, CABG was deemed prohibitive due to technical challenges, and the patient's advanced age and comorbidities. PCI posed its own difficulties, including the complexity of LM trifurcation lesions, the need for debulking procedures such as rotablation, and potential requirement for mechanical circulatory support. Assessing the postoperative outcomes, surgical mortality rates were projected to be high, prompting a thorough evaluation of the risks associated with both procedures. Ultimately, PCI was chosen for this high-risk patient, with successful completion reported. King highlighted the lack of randomized controlled trials focusing on PCI for such complex cases. Instead, he referenced a recent registry study involving over 700 patients who were turned down for surgery and underwent PCI at specialized centers. The study showed that there was no difference in the actual mortality rate compared to the mortality rate predicted by the Society of Thoracic Surgeons score and EuroScore II, and that the symptoms of the patients improved 6 months after PCI compared to the baseline condition (Figure 2). Figure 2. Improvement in patient symptoms 6 months after PCI compared to baseline condition Looking ahead, King emphasized the need for further research to validate these findings and address key questions surrounding the selection of treatment modalities for complex cases. He advocated the establishment of local registries for high-risk patients to inform clinical decision-making. In concluding the lecture, King left a lasting message for interventional cardiologists that no spectacular success will go unpunished and the more tough cases you take, the more you will get, which may be a good thing. As the field continues to evolve, the quest for optimal treatment strategies for the most complex patients remains ongoing. Live Case & Lecture 6: Complex PCI Friday, April 26, 3:30 PM ~ 5:00 PM Main Arena, Level 2 Check The Session

June 19, 2024 1934

TCTAP 2024

Provisional Stenting in Left Main vs. Non-Left Main Complex Bifurcation Stenoses: Is There a Differe...

Scott Harding Wellington Hospital,New Zealand Scott Harding, MD (Wellington Hospital, New Zealand) was the first presenter in the ‘New concept of Bifurcation PCI’ session, highlighting the unique characteristics of the left main bifurcation compared to other bifurcations (Figure 1). The Left main bifurcation is a larger vessel with crucial branches in almost all cases. Notably, the bifurcation angle (B angle) is generally larger, and there is more calcification and fibrosis, particularly at the circumflex ostium. Additionally, the geometry of the left main bifurcation differs significantly from other bifurcations, such as the left anterior descending (LAD) bifurcation. Figure 1. Unique characteristics of Left main bifurcation Importance of the Circumflex and Myocardial Subtension Harding stressed the importance of the circumflex artery, which supplies more than 10% of the myocardium in 90% of cases. In contrast, only 20% of the non-left main bifurcations supply a similar amount of myocardium. It was noted that CT estimates might overstate these figures, suggesting that the actual numbers could be lower. He emphasized the critical need to avoid leaving significant disease untreated in the circumflex, citing high event rates over 5 years for patients with low fractional flow reserve (FFR) who did not receive intervention. Clinical Outcomes: Left Main vs. Non-Left Main Bifurcations Drawing from various registries, including the Coronary Bifurcation Stent III Registry from Korea, Harding illustrated that left main bifurcation interventions typically result in worse outcomes compared to non-left main bifurcations. This discrepancy is likely due to the larger area of jeopardized myocardium in Left main cases. The complexity of the disease also significantly impacts outcomes, underscoring the importance of comprehensive treatment strategies. Optimal Stenting Strategies Harding discussed findings from several trials, including the DKCRUSH-V and EBC MAIN trials, which suggest that complex Left main bifurcations benefit more from a two-stent strategy than a provisional strategy. The DKCRUSH-V trial showed a significant reduction in target lesion revascularization with a two-stent approach, especially in complex lesions (Figure 2). Conversely, the EBC Main trial found a provisional approach to be non-inferior in less complex diseases. These results highlight the necessity of tailoring stenting strategies to the complexity of the lesion. Figure 2. Benefits of two-stent strategy from DKCRUSH-V trial Unintentional Stent Deformation: Insights from the OCTOBER Trial An important point from Harding's lecture was the issue of unintentional stent deformation, revealed in the OCTOBER trial. The trial found that 9% of cases experienced unintended stent deformation, with this rate increasing to 19% in left main bifurcations. Factors contributing to this complication include guide catheter collision and abluminal wiring, particularly in complex left main procedures (Figure 3). This finding underscores the need for meticulous attention during stent placement. Figure 3. Mechanisms and outcomes of unintentional stent deformation Harding concluded by reiterating the differences and challenges associated with left main bifurcation interventions. He noted that the worse outcomes often seen in these cases reflect the large amount of jeopardized myocardium. While a provisional stenting strategy can be effective for most non-left main bifurcations, an upfront two-stent strategy is often warranted for complex left main lesions. These decisions should be guided by the specific characteristics and complexity of the disease. TCTAP Workshops New Concept of Bifurcation PCI Thursday, April 25, 4:00 PM ~ 5:40 PM Valve & Endovascular Theater, Level 2 Check The Session

June 19, 2024 1824

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