<v Dr. Abbott>Oh Terrific. Well, I think we can,</v> pause now, and Dr. Lisko can bring some questions forward to the panel. <v ->Thanks so much Dr. Abbott.</v> We have a lot of great questions in the webinar chat. So, for everyone that's on, if you have any questions, feel free to post them there, and then we can try and work through them over the course of the discussion. So upfront, not a conversation that occurred much, but is there any consideration for mechanical support in these algorithms? And what's everyone's clinical practice? Are you basing it solely on AF, doing right heart CATs, both? <v ->I think that, you know,</v> for elective patients which were stable, who don't have LV dysfunction in all these trials and also all the trials showing that people were not decompensated, you know. They were pretty, they had preserved AF for the most part and also in the excel trials. But, I know, of course, you have LV dysfunction or somebody in the middle of cariogenic shock or, you know, bad Ventris for check the EDP. If the EDP is elevated, I think should get mechanical support. Then, you have very calcified left main vitrification use an atherectimy of any kind you should think of mechanical support. What do you think Charlene, or Yanice, or Don, what are what are your thoughts? <v ->Yeah, I totally agree.</v> We talk about high risk PCI, in which case we, uh we have to consider mechanical support with the Impella or whatever devices we have available. And high risk PCI means high risk complex patient and/or high risk anatomy. For instance, in my case you see that the anatomy is definitely complex. The patient has high risk features like low AF. So one would definitely, wouldn't be wrong to consider upfront mechanical support. <v ->Chon Leng, what do you think?</v> <v ->I fully agree.</v> In my case lab log info, the patient has a left ventricular ejection fraction less than 30%. Definitely then we will use some mechanical support Otherwise if for a year is between 30 and 40%. So Impella or IBP will be set by. Thank you. <v ->Valeria, and what about Holland?</v> What are you doing there? <v ->Absolutely. Absolutely agree.</v> So first of all, consider the ejection fraction of the patient and if it's impaired and the the anatomy is complex, the, of course the use of mechanical support device give you the freedom and the time to complete the procedure in the in the best way. So use of intravascular imaging assess the procedure, pre, pre pre procedure or planning, optimize the procedure. I think that's the main advantage. <v ->I, I think certainly with LV dysfunction</v> if you're considering not using it having a right heart cath and understanding the cardiac output is important. Another way with just the arterial pressure and the LVEDP is to look at the coronary perfusion pressure. Certainly if that's greater than 60 and you don't anticipate prolonged ischemic time you are probably fine without mechanical circulatory support device. But if you are not planning it upfront you must know your access site and options if it becomes necessary. You don't wanna be figuring it out last minute. <v ->And if you're gonna upfront plan to perform atherectomy</v> in a patient with a reduced DF or a borderline reduced DF does your choice of atherectomy device bias you one way into support or not with either shock wave or Rhoda? <v ->For me, not, not particularly</v> because if there is severe calcification and there needs to be plaque modification there's always a risk of ischemia and no reflow. Even though it may be less with one device versus another, it's certainly not zero. And, um, you have different um, causes of ischemia with the you know, IVL, the balloon needs to be inflated for a few seconds at a time. With rotational atherectomy there's a higher risk of no reflow, but it's each device has its own pros and cons and You have to use the best device for your, your situation by imaging or a combination of devices in many cases. <v ->This is actually a question from Dr. Chen,</v> So I feel like it's certainly worth bringing up. How long is the duration of DAPT after left main two stent approaches? <v ->So I would say that there's</v> no clear evidence to answer this question, But the consensus and the experience at this point, without clear randomized data, is in favor of prolonged and strong depth. Especially when we talk about two stents implanted in the, in the left main. <v ->So, Yanice, would you drop aspirin at one year,</v> and just keep Plavix or something else indefinitely or keep them both? <v ->As I said, I believe in the absence of evidence,</v> strong randomized data, the practice, the recommendation from ABC V1 is for strong DAPT and prolonged DAPT for more than a year, actually for many years especially when we talk about two stents in the left main. <v ->So what do you do</v> in China and what do you doing in Netherland? Sorry John, I need to ask different parts of the world what you're doing. <v ->Yeah, usually we prescribe DAPT</v> for one year for two stents in the left main. After that maybe we'll start with aspirin and keep a tight covering. <v ->And doc, when you say strong and prolonged DAPT</v> if you're gonna send someone on Clopidogrel are you checking for responsiveness routinely in these cases? <v ->Yeah, I was gonna state,</v> we don't have any perspective data and, um if you look at the complex there have been studies trying to pull out the complex patients in the shorter DAPT studies and certainly the complication rates and mace are higher if you do say short DAPT like three months and drop either the P2Y12 or aspirin. So I think what is clear is you wanna have that minimum of 12 months. We don't have data one versus the other. I like to preload all of these patients because I think that's the safest way. If you have complications, potentially things like perforations or complications that require, you know getting them off of the, um, anticoagulant rapidly they need to be pretreated. So I pretreat them and if there's generally default to a more potent P2Y12, but if, if using Plavix I would head check the genetics to make sure they're a responder. And in which case it may be adequate but we don't have trial data to support that. But my, my own practice would be to preload them with a potent P2Y12 or to check for response to Plavix. Do a minimum of year, preferred three years, and anybody not high bleeding risk. And if somebody is prohibitive bleeding risk after the one year, drop aspirin continue potent P2Y12, which is, sounds like what Chen Yang is, is recommending as well. <v ->Thank you so much for that great discussion.</v> The, a lot of the questions that are coming in are are about DK Crush and some tips and tricks regarding that technique. So maybe we could save those for later on in the, in the chat.

mechanical support

clinical practice

high-risk PCI

DAPT

DK Crush technique