International Circulation: It has been 13 years after the first TAVR， which is become the “Global” affairin the “Modern” era. What the details easy to be overlooked or others should be noticed in clinical practice?

　　《国际循环》：经导管主动脉瓣置换术从第一例至今已有13年，现在已成为全球性事务。该术式有哪些注意事项，尤其是临床容易忽略的细节？

　　Dr. Genereux: First of all， thank you for the kind invitation. It is my honor to be here and to discuss with you. You are right the TAVR thirteen years ago in 2002 actually was first done by Alain Cribier and his colleagues. Since then the technique has evolved substantially. We are proud and there are 3rd and 4th generation devices， many devices and many valves have become available. I think it was a long journey and a lot of things changed with the device. The device has become smaller which actually has led to less complication. In the beginning， the access and the vascular complication was the main issue. Right now， the profile is better and there is still a small issue but it is not a big issue anymore and after that actually the device is much more predictable to deploy. When we deploy a device we precisely measure all parameters， especially by 3D imaging， so now we are better at placing the device， to predict complication， so I think this is something that we have gotten better and better. I think the device has improved leading to less complications but also the operator became much more aware of the importance of planning. We have learned a lot from the first case in partner where we were sizing the valve or choosing the device based only on the 2D echo which has evolved to the 3D echo and then also the 3D CT scan planning. This has improved the outcome by a lot， we are planning better， we are choosing the patients better， and we have better tools. I think where the next 5 years goes will be very exciting especially with all the new devices; the Sapien 3， the Evolut R， but also all the other valves that are coming and I think the patient will be the big winner. This means we will be able to treat lower and lower risk patients. Right now we are still restricted to high risk patients， I think now we are moving to the intermediate patients， this should be very exciting and I think with improvements in the devices and better techniques we will surely eventually go treat the lower risk patients， so it is a very exciting time in the evolution of the last 13 years. I am very excited.

　　Genereux教授：首先，感谢你们对我的采访，非常荣幸能在此与大家进行探讨。自2002年Alain Cribier及其同事开展首例TAVR以来，TAVR已经经历了13年的发展历程。在这13年中，TAVR取得了非常显著的进展，对此我们感到非常自豪。目前，我们已经拥有了第三代及第四代TAVR设备，很多设备与瓣膜已经得到临床应用。随着多年来TAVR的发展与进步，其相关设备也发生了很多变化，变得更小，很大程度上减少了并发症的发生。TAVR初始应用阶段，主要面临的问题是入路及血管并发症问题。现在，TAVR已经变得越来越好，虽然仍存在小问题，但却没有什么大问题了，其相关设备的应用更具可预测性。在应用TAVR设备时我们已经可以精确测量所有指标，尤其是通过采用3D成像技术，所以现在我们能够更好地植入TAVR设备，更好地预测并发症的发生。因此，我认为，在这方面我们已经做得越来越好。一方面，设备的改善使得并发症的发生减少；另一方面术者也越来越意识到手术计划的重要性。随着由原来的仅根据2D超声结果来选择瓣膜大小及设备向根据3D超声结果以及3D CT扫描结果发展，我们已经有了更好的工具，能够更好地制定手术计划，更好地进行患者选择，这将在很大程度上显著改善患者的结局。我认为，未来5年内将是TAVR领域发展过程中令人振奋的五年，将有很多新设备（如Sapien 3， Evolut R）及瓣膜问世。随着该领域的发展与进步，患者无疑将成为最大的赢家，因为我们将能够采用该技术治疗越来越低危的患者。

　　目前来说，TAVR的应用仍仅限于高危患者，并逐渐开始在中危患者中应用，这一点是令人激动的。随着TAVR设备的改善及技术的进步，我们将有望最终将TAVR应用至低危患者中。总的来说，TAVR过去13年的发展令人振奋。

　　International Circulation: Along with the development of PCI， unprotected LM bifurcation lesion never be the absolute contraindication， which is increasingly treated with PCI recently. And SYNTAX trial provide more choices to lower risk patients. Could you please introduce the development of LM bifurcation lesion treatment?

　　《国际循环》： 随着导管介入技术的快速发展和技术的不断进步，无保护左主干病变的经皮冠脉介入（PCI）治疗已不再是绝对禁忌，并且逐渐增多。特别是SYNTAX的研究结果让低危患者有了更多治疗选择。纵观左主干病变治疗的多年发展，您认为其中有哪些里程碑？

　　Dr. Genereux: So left main PCI is also a very exciting topic. Of course all the stents have improved as with TAVR， we now have very safe second and even third generation DES making the PCI bifurcation safer. Today the guideline recommends left main PCI as a good alternative to surgery when you have a low SYNTAX score and showing benefit and mortality actually when compared to CABG so I think left main PCI is a very good strategy for simple left main. If you have an ostial lesion， only one arm affected left main， I think this is a very good valued alternative. When you talk about 2 or 3 bifurcation， complex left main， trifurcation， now this is where we have to sit with the heart team and the surgeons to discuss what will be the most appropriate technique for the patient. If the patient is low risk for the surgery， if they are a young patient with no other comorbidities then I truly believe that CABG is a good option. Of course the EXCEL trial which is now complete will give us much more insight to the question， maybe we will prove again what SYNTAX showed meaning that the lower risk patient in the lower risk anatomy based patient， meaning no trifurcation， no wide angle， no calcification， would prove to be a useful technique but we have to wait for the EXCEL trial. On the other hand， like I said， for the patient with a very complex trifurcation， I think CABG is a good option. Otherwise， however， if the patient is not a good candidate for surgery， if they are very old， very sick， or have lots of comorbidities， then PCI is a good technique and now we need to choose how we say simple as better. Keep it simple， the provisional technique is a good technique when you can， use imaging – this is very important， and if you have to use 2 techniques， you need to know which technique to use. I really like the DK crush， the double kissing crush which was developed here in China which I think covers the ostium and the carina very well. That is my preference because I am very comfortable with this technique but I think the most important thing is to be comfortable with the technique you are using in this type of ultimate bifurcation. The culotte is a very good technique if the two branches are very similar in size so I think if you jump into a left main bifurcation complex， you really need to know your technique and your strategies and try to choose wisely. The other area of growing interest is the dedicated bifurcation stent. The Tryton trial shows actually some benefit in large side branches (more than 2.5) and there is a lot of data accumulating with the stent in the left main so I think that will be very interesting to see the future of this stent. I would say in general， and in our practice， simple left main with a SYNTAX score of less than 22 could be done by PCI if there is no anatomic feature that makes it dangerous. For more complex left main I think surgery will still be the preferred strategy if the patient is too risky you can try PCI， you can offer PCI with very good two stent technique and the DK crush is a very good strategy.

　　Genereux教授：左主干PCI也是非常令人振奋的一个话题。当然，与TAVR一样，支架也在不断改进，我们现在已经拥有了非常安全的第二代甚至是第三代药物洗脱支架，能够安全对分叉病变进行PCI。目前，指南推荐，对SYNTAX评分较低、与CABG相比PCI具有更多获益可降低死亡率的患者，左主干PCI可作为替代手术治疗的良好选择。我认为，对简单左主干病变患者而言，左主干PCI治疗是非常好的一种治疗策略。当患者存在开口病变，仅一侧左主干分叉受影响，则PCI治疗是非常好的替代选择。对合并两处或三处双分叉病变、三分叉病变的复杂左主干病变患者，我们则需要与心脏团队及外科医生就最佳治疗策略进行探讨。如果患者手术风险较低、较年轻无其他合并症，我认为CABG是非常好的治疗选择。当然，目前已经完成的EXCEL试验将为我们解答该问题提供更多信息，我们有可能会进一步证实SYNTAX研究的结果即对低危的解剖学风险较低即无三叉、无广角、无钙化患者而言PCI是非常好的治疗选择。当然，要想真正证实这一点，我们仍需要等待EXCEL试验的结果。另一方面，对非常复杂的三叉病变患者，我认为CABG是非常好的治疗选择。不过，如果患者不适合进行外科手术，年龄比较大，身体条件比较差或是合并多种并发症，可能PCI也是一种非常好的治疗选择。对这类患者而言，其治疗应越简单越好。如果可能的话，可借助影像学技术行临时支架术，这一点是非常重要的。如果必须应用两种技术的话，则需要知道应该应用哪两种技术。我个人非常喜欢中国发明的DKCRUSH技术，因为其能同时覆盖分叉病变的开口与嵴线（carina）。当然这是我个人的偏好，因为我对DKCRUSH技术非常满意。但是，总的来说，我认为，对这种类型的终端分叉（ultimate bifurcation）患者而言，技术选择时最重要的是确保自己对所使用的技术能用得得心应手。如果两个分支的大小非常形式，则Culotte技术是非常好的选择。因此，我认为，治疗复杂左主干分叉病变时临床医生需要作出明确的选择，知道自己应采用哪种技术及策略。目前，专用分叉支架受到越来越多的关注。Tryton试验显示，其对大分支确实能具有一些益处。目前我们已经积累了很多其在左主干应用的数据。一般情况下，在我们的临床实践中，对SYNTAX评分＜22分的简单左主干病变而言，若不合并高危解剖特征则可行PCI；而对相对更复杂的左主干病变则应首选外科手术治疗策略，如果患者存在较高手术风险则可以尝试行PCI。此种情况下，我们可以通过应用两种非常好的支架技术来进行PCI。其中，DKCRUSH是一种非常好的技术选择。