What is POT and Why to Do It?

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1 San Francisco, TCT 2013, Monday Oct 28, 10:54-11:09 What is POT and Why to Do It? Carlo Di Mario, Alessio Mattesini, Gianni Dall Ara, Nicola Viceconte, Tito Kabir, Gioel Secco, Alistair Lindsay Royal Brompton Hospital, London, UK

2 San Francisco, TCT 2013, Monday Oct 28, 11:33-11:44 What is POT and Why to Do It? Disclosures: Carlo Di Mario Abbott Vascular supports the EXCEL trial at the Brompton Speakers fees from Boston Scientific, Biosensors, Abbott Vascular, Medtronic

3 Lugano, 28 June 2012 Lugano Genova, 10 Ottobre ,267,324 Viewers in 5 months 423,014 Viewers in 6 Years Kissing is Catchy, POT is dull

4 POT and KB: the Finishing Steps of Provisional Stenting Provisional stenting is the accepted standard of care for bifurcational lesions but what do we mean by this: We deploy a stent in the MV across the SB origin finished- CONCEPTUALLY VERY QUESTIONABLE We consider and respect the sudden INDISPENSABLE change in caliper of the MV across the origin of a large bifurcation (POT) PROBABLY We try to HELPFUL, obtain a good ESPECIALLY opening of if 2Stents the SB and implanted minimise strut malapposition at the ostium (KB)

5 What Does POT Stand For? Credit for this definition should be given to Dr Olivier Darremont, Bordeaux, France P roximal O ptimisation T echnique Finet s law D 1 = 0.67(D 2 + D3) D 1 D 2 D 1 D 2 D 3 D 3

6 Lumen Contour Detection Proximal Reference Distal Reference Stenosis 26 mm LCx 10/16534

7 Stent Deployed with Delivery Balloon 3.5 mm at Nominal Pressure 3.5 mm D Underexpansion and Malapposition ( ) x 0.67= 4.0 mm

8 POT with Larger Balloon according to Finet Law ⅔ ( mm) 3.5 mm D 2.5 mm D

9 POT achieves full expansion and apposition and facilitates recrossing 2.5 mm D

10 Guidewire crosses distal cell

11 Final Result Underexpansion and Malapposition 2.5 mm D

12 Methods and Flow chart With thanks to the Natural History Museum, Imperial College SIMPLE SB DILATATION KISSING 45º 3.5 mm 2.75 mm Compliant coronary silicon bifurcation model Anatomy follows scaling laws of bifurcations 3.0 Taxus Liberte after SB dilatation with a NC 2.5 balloon inflated at 10 ATM Focus on strut apposition and Provisional technique

13 A MV SB Dist. B FKI SB-MV 2-Step Sequence C D

14 KB 2 Step Avg. of n= 2x 13 stents (Xience, Biomatrix, Element, Taxus, Resolute)

15 Results after Final Proximal Inflation After Kissing Balloon Final Proximal Correction p value (PCS vs KB) Mallaposed strut prox. (%) 33.4 ± ± * MSA prox. (mm2) 6.8 ± ± 0.6 P< *** MSA dist. (mm2) 6.0 ± ± ns MLD ref. prox 3.0 ± ± 0.1 P< *** Max LD prox 4.1 ± ± ** MLD carina MB 2.7 ± ± ns MLD ref. dist 2.8 ± ± ns Ratio dist/prox MLD 0.90 ± ± * Stent Eccentricity Index 0.72 ± ± 0.04 P< *** Ostial stenosis (%) 21.8 ± ± ns Mallaposed strut at ostium (%) 27.1 ± ± ns MLD: Minimum Lumen Diameter 56 step scanned, 14 different 3.0mm stents (Xience, Taxus, Presillion) MSA: Minimum Stent Area Final ProximaI Inflation ensures complete proximal stent apposition Increases MSA proximal Restores a circular lumen N. Foin, G.Secco, R.Krams and C. Di Mario, Eurointervention 2011

16 Wall strain Finite Element Analysis KB vs SB dilatation and final POT KB High strain SB-MV Foin, R. Torii, P. Mortier, Di Mario et al. JACC Interventions.2011

17 Impact of Proximal Optimisation on Side Branch Access Deployment Deployment after POT * after POT * * * Deployment * after POT * Xience 3.0mm after deployment at NP (9 ATM) after POT (3.5 mm proximal)

18 60 year-old gentlemanwith hypertension, hyperlipidaemia, ex-smoker. Previous PCI on RCA (2009) Worsening angina including angina at rest. LMS disease, with 0.78 FFR. Consented for the EXCEL study was randomised to have a PCI.

19 IVUS IVUS in both LAD and LCX: - ostial LAD stenosis - distal LM stenosis - fibro-elastic plaque - minimal CSA 5 mm mm D 3.4 mm D

20 Distal 3.5, Proximal 5.0: Which Size Stent? (4.0 x 28 XIENCE at 8 Atm) (4.5 x 12 NC at 18 Atm)

21 Angiography post POT Re-wiring LCX Balance PowerTurn KB: LAD NC balloon (24/8 KB) LCX 3.0 balloon (10 alt/8 KB)

22 POT 5.0 mm NC 16 Atm. Final angiographic Result (Double POT/KB)

23 Sequential Technique in BVS A74-year-old lady with hypercholesterolaemia and type 2 DM; NSTEMI After 3.0 mm CB, mm BVS postdilated 3.5 mm proximally

24 Sequential Technique Again 3.5 mm NC at 14 Atm Origin SB dilated with 2.0-mm NC balloon, slowly inflated at 12 ATM

25 Sequential Technique in BVS OCT Foin et al. Eur Heart J Cardiovasc Imaging Jul 24

26

27 POT or Kissing in Bifurcations Conclusions POT is more important than KB which can probably be substituted by SB inflation corrected by final POT POT before kissing/sb dilatation, however, avoids recrossing below struts MV stent and facilitates wire/balloon insertion A double POT is a feasible and practical approach also in BVS with gentle slow SB dilatation

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