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

GRCI 2019 SESSION PARALLÈLE 6 – TRUCS ET ASTUCES AU QUOTIDIEN Mon stent fait le yoyo: comment s’en sortir? Radwan HAKIM Hôpitaux de Chartres

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

Determinants of cardiac motion LVEF Heart rate Relative axial movement Artery / Stent Most movable segments : Distal and mid RCA+++ > Mid and distal LCx > Prox LAD JACC 2015;66(15) :supplB 184-5

« Yoyo stent » 2 - 3% of PCIs

Consequences Longitudinal miss Stent length Am J Cardiol 2008;101:1704-11 Am J Cardiol 2012;110:350-5

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 Low pressure inflation (1-3 atm) => Optimal positioning => Full inflation Disadvantage : Increase the risk of stent loss Cath Cardiovasc Interv 2000;49:102-4

Floating-wire technique J Invasive Cardiol 2015;27:497-500 N = 19 Baseline stent movement 4.04 ± 1.25 mm Stent movement after application 1.11 ± 0.81 mm of floating wire

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

Pacing 160/min EuroIntervention 2007;3:239-42

Rapid Right Ventricular Pacing EuroIntervention 2007;3:239-42

Rapid Right Ventricular Pacing Diastole Systole Pacing 160/min Diastole Systole EuroIntervention 2007;3:235-8

Rapid Right Ventricular Pacing Potential complications • No hemodynamic degeneration • Ventricular perforation • No ventricular arrythmia • Cardiac tamponade • Rapid blood pressure recovery • Access site complications

Guidewire Left Ventricular Pacing during TAVI Rev Esp Cardiol 2018;71:861-76

Rapid Transcoronary Pacing Rev Esp Cardiol 2009;62(3):288-92 Cathode Anode

Rapid Transcoronary Pacing Pacing at slightly higher frequency than patient’s baseline (5V) No evidence Evidence of of failure failure Increase frequency Increase to 100 – 150 b/min voltage to 10V Control angio at both frequencies Select frequency giving best response

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