<v ->Terrific.</v> Well, while Valerie is getting her slides up certainly understanding the complexity of the left main bifurcation, either through the definition algorithm or the simplified algorithm that you presented is important and we'll see what the update is now. <v ->Thank you very much.</v> It's a great pleasure to be here tonight. So I will walk you through an update of the suggested algorithm for left main bifurcation treatment recently published by my working group. So randomized data and data from registry have provided solid basis for a percutaneous treatment of left main bifurcation disease. However, when it comes to uniform recommendations there are none on optimal standing in this setting. And we decided to focus particularly on escalation rate and angiographic intravascular imaging determinants for subsequent stent implantation. When we look at escalation rate from registry we see that the reported rate is quite low but there's probably some bias as patients who received a second stent because of impairment of circumflex is probably because all these patients were classified as a two stents technique. So precluding any insights into scenarios for escalation and also on reliable escalation rate. But also I will look at escalation rate from randomized controlled trials, we see that the rate varies across all the study probably reflecting some different operator choice, different selection criteria, but also different definition for suboptimal circumflex result. And you can see here that among all the study randomized controlled trial and registry, the definition for suboptimal result for circumflex requiring per protocol the implantation of a second stent is quite different. Ranging from angiographic determinants, intravascular determinants and physiological assessment. So we came up with a suggested indeed algorithm and we suggest in our in our algorithm to look first of all at the baseline complexity of the bifurcation lesion before embarking into the procedure. So first of all starting from angiographic determinants look at the Medina classification. So lesion complexity but also bifurcation angle and also include in your assessments. So pre-procedural planning intravascular imaging determinants which can be predictors for side branch occlusion. So look at side branch disease, for example, lesion length longer than 10 millimeters but also plaque morphology. So have a look at plaque burden and also calcium arc higher than 60 degrees. So taking into account both angiographic and intravascular imaging determinants consider to stand strategy. And after that, so talking about a stepwise layer approach consider after crossover standing, which are the angiographic imaging and physiological findings which require an escalation to two stents. So based on angiography, have a look at side branch occlusion of or impairment of TB flow, side branch dissection higher than B or side branch severe osteo pinching, at intervascular imaging side branch medial dissection or MLA lower than four. And look at the functional assessment of side branch impairment by means of FFR or IFR. And based on the impairment of one or more these findings considered to escalate two stents. And of course final assessment with intravascular imaging because it provides information about expansion, opposition of the stents and geometry of the bifurcation. Thank you. <v ->Great, so you just added some levels</v> of sophistication to the original algorithm and certainly those are more things to consider including the addition of imaging, which is nice to see.

algorithm update

treatment

left main bifurcation disease

escalation rate

stent implantation