To evaluate the angiographic and clinical outcome of patients undergoing paclitaxel-eluting stent (PES) implantation for unprotected left main coronary artery (ULMCA) stenosis in a "real-world" ...multicentre, prospective registry. Percutaneous coronary intervention (PCI) is an increasingly utilised method of revascularisation in patients with ULMCA.
A prospective registry including all patients with a significant (>50%) ULMCA stenosis. Of 151 such patients, the target lesion involved the distal bifurcation in 100 patients (66%), which was treated predominantly by a "provisional T-stenting" strategy. In the distal ULMCA disease group, 72% had only one stent implantation while 28% had multiple (either two or three) stents implanted. At a median follow-up of 1,123±80 days, cardiac death occurred in five patients (3.3%) and major adverse cardiac and cerebrovascular events (MACCE) in 32 patients (21.2%). The three-year survival rate was 93.3%.
In the drug-eluting stent era, paclitaxel-eluting stent implantation of ULMCA stenosis provided excellent immediate and long-term results in this selected population, suggesting that this approach may be considered as a safe and effective alternative to CABG for selected patients with ULMCA who are treated in experienced institutions performing large numbers of PCI procedures.
BackgroundLeft ventricular outflow track (LVOT) obstruction (LVOTO) is a severe complication of transcatheter mitral valve replacement (TMVR) procedures, with an uncertain prognosis and only few ...strategies available to prevent its occurrence. TMVR is thus contraindicated in some patients because of a high risk of LVOTO onset. We demonstrate how LVOTO can be managed with a balloon inflation in the LVOT and a D-shaped deformation of the bioprosthetic valve. Case summaryA 64-year-old female presented with acute pulmonary oedema 2 weeks following aortic valve replacement and aorto-coronary bypass surgeries. A concomitant mitral stenosis, secondary to significant calcifications of the mitral annulus, was not treated during the procedure. After surgery, the mitral valvulopathy caused an acute heart failure and TMVR was performed by the heart team. The procedure was complicated by a cardiac arrest secondary to the onset of LVOTO which was managed by a balloon inflation in the LVOT and an alcohol septal ablation. Two-year follow-up shows a favourable outcome of the patient and good function of the prosthetic valve despite its deformation. DiscussionThis case highlights the successful management of a LVOTO following valve-in-mitral annular calcification TMVR by balloon inflation in the LVOT. It is strongly recommended to place a 'rescue' guidewire in transaortic position during TMVR in order to manage the potential onset of acute LVOTO.
The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) ...percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.
Lessons from the real bench: non-BRS Ormiston, John; Darremont, Olivier; Iwasaki, Kiyotaka ...
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology,
2015, Volume:
11 Suppl V
Journal Article
Bench testing of stents used in bifurcations can provide information on the general properties that influence performance including crossing profile, radial strength, recoil, flexibility and ...radiopacity. Problems with device delivery can be clarified. Bench testing identified that side branch dilatation caused stent distortion and elucidated correction strategies. Bench testing led to a stent design change adding connectors between hoops to help overcome the clinical problem of longitudinal distortion. Testing on the bench can determine best deployment strategies and showed that a two-step post-dilatation strategy produced the best deployment with "crush" stenting. Scanning electron microscopy showed that withdrawal of a coronary guidewire trapped between a stent (or scaffold) and a mock arterial wall during a provisional side branch stenting strategy caused only mild linear polymer coating damage. Stent fracture can cause adverse clinical events and our repetitive bend test identified the stents most resistant to fracture. Causes of obstruction of the passage of a balloon over a wire through the side of a stent include damage to the catheter tip, complex cell geometry and inadvertent passage of a wire behind a strut. Bench testing plays a major role in validation of computer modelling of bifurcation treatments and flow alterations.
Technical aspects of the provisional side branch stenting strategy Darremont, Olivier; Leymarie, Jean Louis; Lefèvre, Thierry ...
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology,
2015, Volume:
11 Suppl V
Journal Article
Provisional side branch (SB) stenting is the recommended treatment strategy in the vast majority of bifurcation lesions. Over the past 10 years, advances in fundamental knowledge have led to a better ...understanding and to improvements of this technical approach. This strategy has reached maturity, and long-term clinical results are now comparable to those of non-bifurcation lesions. This paper describes in detail simple rules and tips and tricks which may help physicians in daily practice to use provisional side branch (SB) stenting as the gold standard treatment for the majority of bifurcation lesions.
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