2019 Scientific Sessions

Title Software emulated moving superposition of the coronary tree on fluoroscopy as a guidance tool in imaging of the collaterals in successful antegrade left anterior descending CTO recanalisation Introduction Taking advantage of the recently released software for superposition of the moving coronary tree on fluoroscopy (Dynamic Coronary Roadmap; Philips Healthcare, The Nederlands), we developed a method that allows the operator to perform an antegrade PCI of a CTO lesion relying solely on the coronary roadmap of the collaterals from the other coronary artery obtained at the beginning of the procedure and overlaid to the live fluoroscopy, thus providing a precise guidance. The moving structures that are present in both the roadmap and in the live fluoroscopy images are a precise overlay of the coronary vessel tree, the combination of the two moving exactly with the cardiac and beating motion. The showing of the collaterals is good and the antegrade wire passage and stenting is conducted without any further need of contrast medium injection from the other cornary artery. Maintaining a locked-table position is crucial for the success of the procedure. Clinical Case A 68y old male, treated for pulmonary oedema, paroxysmal atrial fibrillation and heart failure. He is clearly simptomatic on low grade exertion. CTO LAD after S1 with average collaterals from RCA. Myocardial perfusion scan showed an anterolateral reversible ischaemia (32% of the myocardium) which was viable in 70% of the area and an lower ejection fraction of the left ventricle of 35 %. On echo there was apical akinesia, lateral hypokinesia and moderate MR. Right radial access, EBU3,75-6F. No contrast was used during PCI. The DCR was superimposed on fluoroscopy in cranial RAO projection. A Sion guidewire with the support of a balloon was used to cross the occlusion and positioned in the D1. With the 2nd Sion wire we crossed into the LAD. The software superposition of the coronary tree gave excellent and reliable mapping of the collaterals of the LAD from the RCA to safely land the wires in the LAD/D1 respectively. The lesion was dilated with multiple semicompliant baloons multiple times and then LAD/D1 was stented with DK crush technique (1 DES in D1 and 3 DES in LAD). Discussion DCR guided antegrade PCI of a CTO lesion with monocannulation can be considered as a safe alternative to the classical antegrade approach with bicannulation. The software overlaying of the images on the live fluoroscopy is excellent and mapping of the collaterals is precise. Furthermore, the need of contrast agent injections are minimized as well as radiation exposure and no bicanulation is needed, thus less vascular complications and lower haemorrhagic risk.