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
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