Okay, thank you first for Sky to give me the chance to share with you this 15-minute talk and case presentation. That is a presentation that I already performed at CVS meeting with our friend Xiaolian Chen. That is the left main stenosis, no disease in the CERC, the CERC was widely open, it's the best situation, you can go from to the left main to single stent to LAD like this and that is the end of the procedure, this patient that is the one year later the angio. That is different that this guy with only stenosis in the circumflex, the lateral ventricular branch was protected passively, we use only a guide wire, we put stent all through and thereafter we have to do a tap stent to the obtuso-marginal branch and that is the final result. Now we move to the worst scenario for me in bifurcation, which is the left osteal CERC, this is a good case that I would like to share with you, that is also a trifurcation but the intermediate branch is very, very small and we select to use a culotte technique, in this case the size of the left main and the CERC were similar, I love the culotte technique because it's very easy to, in one single movement you protect the CERC and also the left main, that is the case, the stent, okay I do everything, I do pod, kissing, balloon, etc, etc, that is the final result, looks quite well, however after the patient came back and that is the result. Let me show what I, what we learn with bifurcation, we use not the syntax code when we are going to treat the bifurcation, we follow this score, the ORACHI, where we excluded small vessel and also excluded intermediate lesion and that allows us to be more conservative when we are going to treat bifurcation lesion, if we look the data from Excel, the Excel trial have many lesions classified as low risk by investigator because they don't count intermediate lesion and they don't count small vessel, however when the angel go to the core lab, this guy for the core lab, 25% was classified as a high syntax code. What I learned with the definition, some of you were involved in this trial, the leading author was Professor Chen, you can see here left main and other sort of bifurcation, all the cases, the bifurcation should be complex, in our experience only few bifurcation cases will be able to be randomized and included in this study, we can see here left main and low and non-left main stenosis, 300 people in one improvisional and the same in two-stem technique, the people from China use Dickey-Grass in most of them, I have to say the people from Asia, in all my case, I use Kulop, the two-stem technique in this particular high risk complex bifurcation was better in two-stem technique compared single provisional, we can see here the incidence of target lesion failure at 30 days and the incidence of myocardial infarction was significantly lower in the two-stem technique compared to provisional and also that was the results at one year in favor to the two-stem technique, however when we look the data at three years there is no difference beyond the first year of follow-up, what happened with the use of DCB and bifurcation, again the people of China do this trial and follow-up at three years, the bifurcation stenosis was quite complex, if we look the medina, the incidence of left main, also the incidence of LAD and the result was much better, significantly better when you use drug eluting balloon compared to non-compliant balloon, these are the PCI technique of interest, 25% only of this cohort of patients using intravascular imaging and that is probably a limitation of this study, the result was better with drug coating balloon that compared to non-compliant balloon. Let's go quickly to two cases, this is a case with several risk factors, previous stenting in left main to LAD and follow-up the patient developing stent stenosis in the osteocere and we do at the follow-up PCI with that technique as we can see here in the, let me see, as we can see here in this view, this is the final results, quite nice and geographically, however very soon the patient developed chest pain and complete closure of the cell as we can see here, at this time we do again PCI POVA and drug eluting balloon, we can see here we use that is post-POVA, at this point we use a drug eluting balloon, the drug eluting balloon has some advantage to other eluting balloon because they, at least what the industry say, they didn't, they didn't lose a drug when they cross the guiding catheter and when we cross the lesion that is a difference between this drug eluting balloon and the other branch of eluting balloon, that is the final results after drug eluting balloon, we can see here and this is immediately after and 15 minutes after, why we do 15 minutes and you, we can see here there is not recoil in any segment by online QCA 15 minutes after and that's if we, if we trust this data, you don't have recoil, the stenosis was very, very low, that is the drug eluting balloon that we use, there is a paclitaxel, the most important thing allow multiple inflation at the green seal technology that we, the device allow not to lose drug during all the process of the cross, the guiding catheter and the lesion. Let me see this case and this case we can discuss deeply, it's my worst case that ever I have, the patient of my, from my private practice, I deployed a self-expanding valve in 2016, in 2020 we do PCA to the DS, approximate right and also in main portion of the LAD and now he presents with ST elevation in inferior lip, that is an acute myocardial infarction. Let me see, we start with the left as usual, the left main tree is very easy to catheterize whatever valve you use, balloon expandable or self-expandable, the, in my experience, left, left main is very easy to catheterize, however, the right is completely different, we can see here the patient have complete closure of the DP and also the AB distal branch, you can see here we are trying to engage here, the guiding catheter looks well engaged but that is not true, we go with two wires, with two wires, we lost a good guiding catheter support and was that, look this, the guiding catheter, we have not coaxial support and it was impossible to go through with the stem or whatever in the distal portion of the right with this sort of guiding catheter. So what next, what next? We change the guiding catheter, I spent one hour doing the PCA, this PCA yesterday, finally we be able to achieve a very deep intubation with the right coronary artery, you can see here, and after the deep intubation, I'll be able to go with the, with both stem and also with the drug coating balloon to the distal portion of the right, That is the drug eluting balloon now. And that is the final view. Immediately the end of the procedure, nice results. And we go 15 minutes later, very good result 15 minutes later. So we were quite comfortable with the results of the PCA. Yes. My fellow when I withdraw the the stance, I'm sorry, the balloon and also the wire. I was in my office, speaking with the family. And at that time, my fellow called me, I go back to the to the room. And we see that they cannot pull back take out the guiding catheter from the oxygen of the of the right of the right coronary artery. We can see here this view, I'm sorry. That is the guiding catheter. And the guiding catheter stay there. So we spend another one hour and a half trying to take out the guiding catheter, the down guiding catheter to the oxygen of the right, we go for the right. I'm sorry, for the left artery to take the to try to take the guiding catheter with the legs, not able, doesn't work, we go for the left radial artery, we can see here, that was impossible. Doesn't work. So finally, after one hour and a half trying to take out this stupid guiding catheter, I call the surgeons, I have to call my surgeons. That was yesterday. I began the procedure at two o'clock in one o'clock p.m. I finish the story at 8pm. So I call the surgeons and send the patient to surgery. That is the self-expanding valve. And that is the guiding catheter. We can see here the guiding catheter most clearly. That is the guiding catheter here. You can see the guiding catheter was completely stuck between two struts of the self-expanding valve. That is what the guiding catheter looks like. And that is the final result. The patient is very, is okay right now. So we don't have, I don't know if you have some experience like I have had yesterday, but it was my first time. So I don't want that any of, including my worst enemy, repeat the experience that I had yesterday. So, complex bifurcation may primarily be treated with a bifurcation strain technique. However, it's not frequent to see complex bifurcation needing Dickey crash or pull out like George and Carlos clearly showing in his really difficult cases. Complex bifurcation was in our setting less than 2%, I'm sorry, 10% for all our bifurcation screening when we include the patient to definition. It's very important to look the size of the bifurcation and also the degree of the stenosis in the side brand to decide what we are going to do when the bifurcation. Kissing balloon and post-tenting in almost 100% of bifurcation. Drug coated balloon I think should have should be a good option in many bifurcation we need more data, of course, but particularly in some very complex region like, like osteocytes, I really hate the osteocytes. And I think everybody, every of us hate osteocytes too, especially particularly when it's a single vessel disease and appears and we look a single vessel in the osteocytes, that is the worst scenario. Osteocytes in our experience is always a nightmare for the PCA operators and for the patient, particularly if a single vessel disease, if you have multiple vessel disease, it's more easy to decide because you can send this patient to surgery. Again, thank you, my friends of CHI to give me the chance to share these cases with you. Thank you. Alfredo, this was such an amazing case. You had the bifurcation of the corvalve stent with the RCA guide. I could never imagine what kind of a bifurcation that is. The main branch was the valve and the side branch was the RCA guide. That was a very, very educational case. I mean, I have to say that if the guide wasn't going, I would probably try to advance a Godzilla or a gun liner or something like that through. And, you know, maybe that's smaller, that might have perhaps not get stuck. At the same time, I don't know how far you would go with that because you had a lot of problems expanding or I mean, passing equipment through this tortuous and calcific RCA. That was also a little ectopic quite frankly, that's why the guide wasn't really sitting well at all. There's a very educational case that made me miss. Buenos Aires cases, Sanatorio Tamendi, we have to show up again. Great. That is a, you know, hardcore of a lifetime bifurcation club. Okay, that's great. Excellent. Any comments, first of all, by our two panelists over here, and Dr. Kalik and Dr. Bortnick, and maybe a question, a question, is there any percutaneous option to expand the stent strut, you know, of the the valve? Is there something some way to try to release it? I try when you I try everything I promise I go with a 5.0 balloon inside the guiding catheter and inflate at the side of the of the struts inside the guiding catheter to height atmospheres and nothing happened. I go with the I go with the Yeah, it was it was and then became like a zigzag. Yeah. And when I pull back the guiding catheter, the patient say, Doctor, I saw chest, I saw discomfort in my chest. So the aorta moving. Yeah, yeah, you probably had a lot of you probably had a lot of steak for lunch in in Argentina steak, and you push him with a lot of power over there. Yeah, I do have a question. Professor Rodriguez, that was excellent. Both cases. I see this that you know, we're, you guys are ahead of us in the use of DBS and DCBS. And we're now beginning to use them for native vessels, side branches, small vessels, so on and so forth. I see that you're routinely doing 15 minutes, you know, wait after the DCB inflation waiting for 15 minutes and doing another NGO. Is this a routine practice that we should adopt as well? Because we sort of missed that window where we you know, we missed the we missed the PTA window. We weren't I wasn't practicing back then. I guess we are so used to stenting. And you know, we don't routinely do this. Could you give your tips and tricks around use of usage of DCB and you know, how comfortable you are with leaving dissections and what kind of dissections can be left alone? And yeah, you know, yeah, one minute, Alfredo, one minute or less. Tips and tricks about DCB, Alfredo. Yeah, inflate and take out or what do you how do you do? I inflate the DCB, I inflate in 30 seconds. Yeah, 30 seconds. That's a sort of DCB, you can inflate three or more times. And you and the another advantage, there is non compliant, and you can use to in different atmospheres in different places. For instance, I can treat the diagonal branch with low atmospheres 2.5 and go to the LED and treat with up to 20 atmospheres, you know, that is another advantage. And the other advantage is that we suppose that we don't lose the immunosuppressive drug in all the process when we cross the lesion or when we go to through the guiding catheter. Of note is I review the experimental data of many DCB where you see they are losing a percentage of immunosuppressive drugs during the process of go through the guiding catheter and go trying to cross the lesion. So that is another advantage. George, excellent. Excellent. In 30 seconds. We have about 10 seconds to go. And I'd like to thank Dr. Rapp for the leadership in this webinars, Carlos Uribe from Chile, Ricardo Costa from Brazil, Alfredo Rodriguez from Buenos Aires, Argentina, and my associates here in New York, Anna Bornyk and Azma Khalik from Montefiore Medical Center. So long from Sky Bifurcation Club.

bifurcation interventions

cardiology

stent techniques

drug-eluting balloons

myocardial infarction

interventional cardiology