Good morning. I would like to share with you a case that would lay the foundation to, for discussion on two stents in coronary bifurcation, but in the setting of STEMI and cardiogenic shock. I have no disclosures. This is a 71-year-old gentleman with history of hyperlipidemia who presented to our emergence room with one hour of chest discomfort. The black and white EKGs, the EMS EKG, showing a marked ST elevation in precordial leads. The pink EKG is the first EKG we obtained when the patient got to the emergence room. And you can appreciate the interval development of the right bundle branch block, which is never a good sign. The patient was in a lot of pain, but hemodynamically stable, no evidence of shock at that time. Lactate was 1.5. He met the criteria for STEMI D2 enrollment. We talked to him about the trial, and he agreed to proceed. So he was enrolled in STEMI D2, was brought up to the cath lab, still very stable. As per protocol, we started the procedure with a peripheral angiogram. But you notice that as we're taking a look at the picture in front of our eyes, the patient becomes bradycardic, hypertensive, and developed a BT and needed to be shocked twice. So he self-excluded himself from the trial at this point. Impella CP was placed, brief chest compressions, and then we initiated Libifest for further hemodynamic support. And here's the first picture. You see a big thrombus burden in the distal left main occluded LAD. We wired both and performed aspiration thrombectomy first. And this is the picture we have. You still notice a high thrombus burden. Appears to be ruptured plaque into the distal left main with extension into both osteo-LAD and osteo-CERC. Any thoughts as to how to proceed at this point? Internal stenting to stent strategy. Any thoughts? So at this point, we have a patient in cardiogenic shock, quite unstable. There's only one objection here, and that is to keep it simple. I knew that Dr. Hashim will be here, so I made sure that I have some IVUS slides because that would have helped us. I would have loved to get away with just one stent and provisionally treat the CERC if needed. But we figured that stenting into the LAD, IVUS-ing the left main into the LAD, left main into the CERC should help us decide. Again, this is another picture. After further aspiration thrombectomy, you also notice that we have very sluggish flow down into the distal LAD. But you appreciate that there is high-grade stenosis of the osteo of both LAD and the CERC into the left main. These are IVUS images. The first one is left main into the LAD. You appreciate a very nice-looking ruptured plaque right at the bifurcation, and the second one is left main into the CERC, again highlighting a high degree of stenosis in the osteum of the CERC, which gave me a little bit of a concern about the provisional stent strategy. So we, at this point, committed to a two-stent strategy, but the question is, which one? What would you do? What kind of two-stent strategy? Two. DK. DK? Okay. Mini-crush. Which one? So this is what I elected to do, just kissing stent. The patient was very unstable, and we just wanted to go in with the quickest and the simplest way of treating this bifurcation lesion. And then kissing balloon, and this was the final result. We still have struggles with the distal embolization in distal LAD and the no-reflow. This is the echocardiogram on day one. The patient went to CCU. Peak troponin was only 42. He was on low-dose levophed the first day, which was weaned in a few hours. We do adhere to ceramics protocol in the management of Schockner institutions, so there was continuous monitoring of the CPO, which was 0.9 for most of the day, and PAPI was 1.1. On day three, Impala was removed in the cath lab, and here's the echocardiogram on day five when he was discharged with marked improvement of his LV function, still with some segmental wall motion abnormality in the apex, but the patient went home on guideline-directed medical therapy, including aspirin, paracetamol, interest, sojordian, spironolactone, and atorvastatin. He just had his one-year visit, and he has a complete recovery of his function and is doing great. I just wanted to briefly mention the timeline of the guidelines and the trials that set the stage for the guidelines over the last decade, and wanted to just briefly mention the data for the last two trials as it pertains to randomized trials for DK-CRUSH or two-stent strategy versus provisional stenting and left-main bifurcation. So in the DK-CRUSH trial, the provisional stenting was compared to DK-CRUSH stenting. In the population, it was mostly stable coronary artery disease, but they did include patients with myocardial infarction. And what they showed at three-year follow-up is that the DK-CRUSH had better outcome at three years as it pertains to TLR, target vessel MI, and target lesion failure. And as you can see, over time, the curves are continuing to diverge. The other important trial is the European trial, the European bifurcation club left-main coronary study, randomized comparison of stepwise provisional versus systematic dual stenting strategy. And they did not show any statistically significant difference between the two strategies. In fact, in their cohort, provisional stenting had better outcome. And the outcome that they looked at was mainly clinical outcome of revascularization and death or MI. What's important to remember from these two trials is that EBC-MAIN was only including patients with stable CAD. DK-CRUSH included stable CAD, unstable angioid and MI. What's missing from all these cohorts and when there is really positive data is how to treat left-main stenting in the setting of cardiogenic shock. We have no data, but I can only advocate that we should try to keep it simple. Thank you.

STEMI

cardiogenic shock

Impella support

bifurcation lesions

DK-CRUSH