"Inverted" provisional T stenting, a new technique for Medina 0,0,1 coronary bifurcation lesions: feasibility and follow-up.

AIMS: Isolated, high-grade coronary bifurcation lesions located at the side branch (SB) ostium (Medina type 0,0,1) are uncommon and their specific treatment has not been described. METHODS AND RESULTS: We have developed an "inverted" technique for the treatment of these lesions, derived from the usual provisional T stenting. We implant the stent from the proximal main branch through the SB, with reopening of the strut through the distal main branch (DMB) and systematic final kissing balloon. We retrospectively reviewed results in 40 patients. The procedural success was 100%, no failure was observed to rewire the DMB or perform the kissing balloon, and a second sent was implanted in the DMB in only three patients (7.5%). No death, myocardial infarction, stent thrombosis or repeat revascularisation occurred within the first 30 days of follow-up. At a mean of 22+/-14 months, three patients underwent repeat percutaneous coronary intervention (7.5%), with target lesion restenosis (n=2; 5%), other vessel treated (n=1, 2.5%), target lesion revascularisation (n=1; 2.5%), and target vessel revascularisation (n=1, 2.5%). CONCLUSIONS: The "inverted" provisional T stenting technique was safe and highly effective in the management of Medina 0,0,1 coronary bifurcation lesions. Larger trials are needed before its routine application can be recommended.

Optimal stimulation of the left ventricle.

Cardiac resynchronization therapy has been proposed to alleviate heart failure symptoms refractory to classic drug treatment. Potential benefits hinge on a number of key components, including judicious selection of patients likely to respond to the therapy and appropriate placement of the leads, particularly the lead responsible for left ventricular pacing. Evidence of ventricular asynchrony is an individual prerequisite for consideration of cardiac resynchronization therapy. Ventricular asynchrony can be diagnosed by recording a QRS duration >150 msec or during echocardiography, with the goal of investigating the mechanical aspect of asynchrony. The optimal left ventricular pacing site can be defined by the latest segmental contraction, which is mainly the mid-lateral wall. The first-choice technique to initiate left ventricular pacing consists of a transvenous approach via the coronary sinus tributaries. In practice, the final left ventricular pacing location also depends on highly variant coronary sinus anatomy, acceptable electrical parameters, and lead stability. Procedure-related complications, which consist mainly of coronary sinus perforation and phrenic nerve stimulation, remain low (<1%) and should decrease further with the use of new features specific to the procedure.