TCTAP 2013 Fellowship Course L ftM i d Bif ti PCI Bif ti PCI TCTAP 2013 Fellowship Course L ftM i d Bif ti PCI Bif ti PCI Left Main and Bifurcation PCI: Bifurcation PCI Plaque Shift vs Carina Shift Left Main and Bifurcation PCI: Bifurcation PCI Plaque Shift vs Carina Shift Plaque Shift vs. Carina Shift Prevalence and Implication Plaque Shift vs. Carina Shift Prevalence and Implication S Ji K MD PhD Soo-Jin Kang, MD., PhD. Department of Cardiology, University of Ulsan College of Medicine Asan Medical Center Seoul Korea Asan Medical Center , Seoul, Korea
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TCTAP 2013 Fellowship CourseL ft M i d Bif ti PCI Bif ti PCI
TCTAP 2013 Fellowship CourseL ft M i d Bif ti PCI Bif ti PCILeft Main and Bifurcation PCI: Bifurcation PCI
Plaque Shift vs Carina ShiftLeft Main and Bifurcation PCI: Bifurcation PCI
Plaque Shift vs Carina ShiftPlaque Shift vs. Carina ShiftPrevalence and ImplicationPlaque Shift vs. Carina ShiftPrevalence and Implication
S Ji K MD PhD
pp
Soo-Jin Kang, MD., PhD.
Department of Cardiology, University of Ulsan College of MedicineAsan Medical Center Seoul KoreaAsan Medical Center, Seoul, Korea
Disclosure
I h hi di lI have nothing to disclose
Mechanisms of Angiographic SB JailingStent Strut ArtifactStent Strut Artifact
Post-stentingPre-procedural
After cross-over
NoboriMLA 8.4mm2 MLA 8.3mm2
Nobori
Pre-procedure After Cross-Over
SBCarina Shift
SB
∆V/∆L >1
MBMB∆P <0
A ChArea Change∆L -3.4 mm2
MBMB
∆V -3.5 mm2
∆P 0 1 mm2
SB pullbackSB pullback
SB MLA 7.2 mm2 SB MLA 3.8 mm2
∆P -0.1 mm2
EEM area 9.3 mm2
P+M area 2.1 mm2EEM area 5.8 mm2
P+M area 2.0 mm2
After MB stentingPre-procedure
Plaque ShiftPlaque Shift
∆V/∆L <1∆V/∆L <1∆P >0
SB FFR 0.77
Area ChangePB 52% PB 70%
g∆L -1.0mm2
∆V 0 3mm2∆V -0.3mm2
∆P +0.7mm2
SB MLA 2.3 mm2
EEM 5 0 2SB MLA 1.4 mm2
EEM area 5.0 mm2
P+M 2.7 mm2EEM area 4.7 mm2
P+M 3.3 mm2
Plaque Shift vs. Carina Shift
Prevalence of Carina vs. Plaque Shift Impact on Functional Significance
Distal MB segment Proximal MB segmentDistal MB segment Proximal MB segmentPre Post p Pre Post p
Plaque VI 5.4±1.8 5.3±1.7 0.227 9.1±3.0 8.4±2.4 0.001
V l VI 9 0±2 5 11 3±3 1 0 001 13 2±3 6 15 1±3 5 0 001Vessel VI 9.0±2.5 11.3±3.1 <0.001 13.2±3.6 15.1±3.5 <0.001
Luminal gain is not caused by plaque shift but by EEMLuminal gain is not caused by plaque shift but by EEM expansion, leading to carina shift and SB compromise
Koo et al. Circ Cardiovasc Interv 2010;3:113-9
( 23 LM bif ti l i )(n=23 LM bifurcation lesions)
Kang et al. Circ Cardiovasc Interv 2011;4:355-61
Hemodynamic Impact of Changes in Geometry of Non LM Bifurcation Geometry of Non-LM Bifurcation Non-LM bifurcation lesions with SB ostial DS<50%
SB MLA (mm2)3 5±1 32 8±1 2
EEM (mm2)6 3±1 95 5±1 7
P+M (mm2)2 8±1 52 7±1 3
Eccentricity1 1±1 11 4±0 2
6 0
7.0 12.0
1 8
2.0
7.0
8.0
3.5±1.32.8±1.2 6.3±1.95.5±1.7
p<0.001
2.8±1.52.7±1.31.1±1.11.4±0.2
p<0.001 p=0.215p<0.001
5.0
6.0
8.0
10.0
1.6
1.8
5 0
6.0
7.0
3.0
4.06.0
1.2
1.4
3 0
4.0
5.0
1 0
2.0
2.0
4.0
0 8
1.0 2.0
3.0
1.0
pre post
2.0
pre post
0.8
pre post
1.0
pre postp p p p p p p pKang et al. Catheter Cardiovasc Interv 2013 in press
Plaque Shift + Carina Shift
1.0
Plaque Shift Carina Shift
45%0.5
45%+M 0.0
∆P+
-0.5
-1.0Isolated
Carina Shift55%
3 02 52 01 51 00 50
Carina Shift
∆V/∆L3.02.52.01.51.00.50
Kang et al. Catheter Cardiovasc Interv 2013 in press
Plaque Shift vs. Carina Shift
Prevalence of Carina vs. Plaque Shift Impact on Functional Significance
SB ostium with pre-procedural DS<50%p p48% were angiographically jailed (DS>50%) after MB stenting while 15% had FFR<0 80after MB stenting, while 15% had FFR<0.80
After MBstentingstenting
AMC preliminary
How Often Functional SB Compromise?
50
40 38%0
(%)
20
3020%
R<0
.80
20 13%10FF
R
<30% 30-50% 50-75%
Pre-procedural SB %DS
30% 30 50% 50 75%
Kang et al. Am J Cardiol 2011;107:1787-93
How to TreatHow to TreatAngiographic Jailing of SB?
FFR 0 75 i f f d f l f j il d SBFFR >0.75 is safe for deferral of jailed SBFFR guided provisional SB interventionFFR-guided provisional SB intervention resulted in a low rate of 9-month MACE
Kang et al. Catheter Cardiovasc Interv 2013 in press
Impact of Carina Angle 0
-10rea
(%)
10
-20
-30umen
a
30
-40
-50carin
a l
r=0.458
16014012010080604020
-50
-60
%∆
LCX
p=0.028
Distal carina angle (°)
%
A narrow distal carina angle predicted a greater reduction in MLA and EEM area at the LCX ostiumreduction in MLA and EEM area at the LCX ostium
Kang et al. Circ Cardiovasc Interv 2011;4:355-61
Summary
Carina shift is a general mechanism of SB Carina shift is a general mechanism of SBjailing, occurs in almost all lesions
Plaque shift is less frequent, but moreaggressive mechanism of the functional SBcompromisecompromise
Considering the frequent visual functional Considering the frequent visual–functionalmismatch, treatment of the jailed SB shouldbe based on post-stenting SB FFR