Mon stent fait le yoyo: comment sen sortir? Radwan HAKIM Hpitaux - - PowerPoint PPT Presentation

Mon stent fait le yoyo: comment s’en sortir?

Radwan HAKIM Hôpitaux de Chartres

GRCI 2019 SESSION PARALLÈLE 6 – TRUCS ET ASTUCES AU QUOTIDIEN

DÉCLARATION DE LIENS D'INTÉRÊT AVEC LA PRÉSENTATION

Speaker's name : Radwan HAKIM, Le Coudray ☑ Je n'ai pas de lien d'intérêt potentiel à déclarer

Heart rate LVEF Most movable segments : Distal and mid RCA+++ > Mid and distal LCx > Prox LAD

JACC 2015;66(15) :supplB 184-5

Determinants of cardiac motion

Relative axial movement Artery / Stent

« Yoyo stent »

2 - 3% of PCIs

Am J Cardiol 2008;101:1704-11 Am J Cardiol 2012;110:350-5

Consequences

Longitudinal miss Stent length

Little tips

Decrease the force of the contrast injection (gentle injection) Withdrawal of the guidewire more proximally Guidewire very distally in the coronary bed may increase stent movement due to an « anchoring effect »

Little tips

Adenosine injection Asystole : short and unpredictable Emergence of heartbeat during implantation => displacement of the stent Direct stenting Entrapment of the stent by the lesion But : Not always possible Stent underexpansion

Deep guide-catheter engagement

Disavantages:

• Pressure damping
• Coronary vessel injury
• Catheter tip may extend into the lesion

Deep guide-catheter engagement

Partial balloon inflation

Cath Cardiovasc Interv 2000;49:102-4

Low pressure inflation (1-3 atm) => Optimal positioning => Full inflation Disadvantage : Increase the risk of stent loss

Floating-wire technique

J Invasive Cardiol 2015;27:497-500

Baseline stent movement 4.04 ± 1.25 mm Stent movement after application

• f floating wire

1.11 ± 0.81 mm N = 19

Floating-wire technique : case 1

Floating-wire technique : case 2

Rapid Right Ventricular Pacing during TAVI

Rapid Right Ventricular Pacing

• Ventricular pacing 120-200/min to reduce stent motion
• 5Fr Pacing wire
• Short duration of pacing
• Remove the wire immediately after stent deployment

EuroIntervention 2007;3:239-42

Pacing 160/min

Rapid Right Ventricular Pacing

EuroIntervention 2007;3:239-42

Rapid Right Ventricular Pacing

EuroIntervention 2007;3:235-8

Pacing 160/min Diastole Diastole Systole Systole

Potential complications

• Ventricular perforation
• Cardiac tamponade
• Access site complications

Rapid Right Ventricular Pacing

• No hemodynamic degeneration
• No ventricular arrythmia
• Rapid blood pressure recovery

Guidewire Left Ventricular Pacing during TAVI

Rev Esp Cardiol 2018;71:861-76

Rapid Transcoronary Pacing

Rev Esp Cardiol 2009;62(3):288-92

Anode Cathode

Rapid Transcoronary Pacing

Pacing at slightly higher frequency than patient’s baseline (5V) No evidence

• f failure

Evidence of failure Increase frequency to 100 – 150 b/min

Control angio at both frequencies

Select frequency giving best response Increase voltage to 10V

Rapid Transcoronary Pacing

Rev Esp Cardiol 2009;62(3):288-92

27 patients included

Rapid Transcoronary Pacing : case 1

Pacing 120/min

Rapid Transcoronary Pacing : case 2

Pacing 150/min

Conclusion

• Longitudinal miss is correlated to more TVR, more stents and higher

rate of MACE

• Various tips and tricks with variable efficiency
• Floating wire : simple and safe
• Right ventricular pacing : potential complications and lengthens the

duration of the procedure

• Transcoronary pacing : easy, safe and very efficient

Thank you for your attention