International Circulation: Can we combine the drug eluting stent and bare metal stent implantation for patients with multivessel coronary artery lesions?

Prof. Morice: It is not common but why not. For example， you have lesions of high risk of restenosis which clearly deserve a drug eluting stent but when some of the lesion， for example on the right coronary artery， very big vessel， short lesion， it is reasonable to put a bare metal stent. So no combination makes sense in some situations.

International Circulation: One focus of treatment strategy for coronary bifurcation lesions is to stent one branch or both. What is the optimal strategy of bifurcation lesions would you suggest?

Prof. Morice: We follow the same strategy since many years， And now I think it is finally beginning to be recognized in many places， provisional T stenting is the optimal strategy for us. That means for us in about 70% of the cases you will require only one stent which is less expensive， less restenosis， and has less chance for thrombosis. And in 25~30% there is a need for a second stent when the side branch is very big or dissected. But stenting the main branch first is the best option.

International Circulation: You have a lot of experience in using Tryton’s side branch stent to treat bifurcation lesions. Could you talk about some of your latest results? What are some of the advantages and perhaps what are some of the drawbacks?

Prof. Morice: About the Tryton stent， we did some cases but not too many. They honestly went very well. I think that this particular stent has some role in the future. The advantage is that it is very easy to deploy and you put the Tryton stent in the side branch first and then you can put any drug eluting stent in the main branch. That is the bigger advantage. For me the drawback is that it is not a provisional stenting approach. It means that you have to put two stents.

International Circulation: When would you perform the kissing angioplasty for patients with coronary bifurcation lesions?

Prof. Morice: Kissing balloon is done in nearly all cases. We have a very good result with that. There is lower stenosis on the side branch increased by the fact that you dilate. And it is often the way for the future because for some patients coronary disease is a chronic one and when the patients return even five or ten years later， if you have a shunt in front of the branch you want to treat， it is not easy. So that is why we always open the vessel at the end of the procedure.

International Circulation: We’d really like to get your views on SYNTAX obviously since you are involved there. Some time has passed since your material was presented at ESC so since ESC what are the developments and how has it impacted people’s views and clinical practices and perhaps some of the feedback and some of the things you’ve heard from other interventionalists?

Prof. Morice: I think that clearly SYNTAX is one of the biggest trials ever done. And there is a lot of information in it. For me， it has already impacted the practice meaning that SYNAX score - which is a score of the complexity of the disease for PCI is used or should be used in all cath labs for complex lesions， meaning that when the SYNAX score is low or intermediate， the PCI can be an alternative to surgery for triple vessel disease or left main treatment which is not the case because clearly the high SYNAX score has a much better outcome with surgery. That is a big impact. I think the second big impact of SYNAX is that even if the primary end point was not met， the sub group of the left main patients can not be used as results. However those results are very good and this trial opened the door to PCI for left main disease in certain subset of patients. And for sure new trials will be needed to confirm that and change the recommendation but it has clearly opened the door.

International Circulation: Has there been any different perhaps regionally， in the United States versus Europe of how SYNTAX has been received， even in Asia? Are there any difference in view or in impact?

Prof. Morice: No， I don’t know， of course I know Europe better than practice in the US or Asia. But I think the consequences will be the same.  If the study of left main I think is even more important in the US where the recommendation is of a left main PCI is a class three recommendation. That means it is completely forbidden. So I think the impact is greater in the US on the left main.

International Circulation: And as a follow-up， how do you think we can best capitalize or take advantage of these results from SYNTAX or perhaps follow up on any studies. What is your view on that? 

Prof. Morice: We learned a lot from these trials concerning the triple vessel disease. It is clear that when the lesions are very complex， surgery is performing better. When the lesions are not so complex， PCI can be an alternative. On triple vessel disease we need more information I think about the diabetics sub group. It seems that in terms of safety it is ok again for the low and intermediate SYNAX score. Safety is not there， surgery must be performed in the complex lesion. But for sure the future trials will have to better stratify the patients， the diabetic patients as it is a very big trial only dedicated to diabetes. For the left main we already discussed that there is a need for another trial on the left main PCI versus surgery.  But probably， SYNAX lets me think that the results will be good.

多支血管病变DES和BMS能否联合应用？

治疗冠状动脉多支血管病变时，再狭窄风险高的病变显然应该应用药物洗脱支架，但一些病变，如右冠状动脉病变或大血管短病变应该使用金属裸支架。联合应用药物洗脱支架和金属裸支架治疗冠状动脉多支血管病变虽不常用但并非不能。

冠状动脉分叉病变的介入治疗

多年以来，对于冠状动脉分叉病变治疗我们一直采用相同的策略。直到现在我们才开始认识到必要时T型支架置入术（Provisional T stenting）是最佳的策略。这意味着大约70%的分叉病变病例只需置入价格相对较低、再狭窄及血栓形成风险较小的单个支架。其他25%~30%的病例，当分支血管较大或存在夹层时需要置入双支架。但首先在主支置入支架是最好的选择。

我们用Tryton侧枝支架治疗了一些病例虽并不多，但疗效很好。我认为这种特殊的支架在将来会有一定的地位。它的优点在于操作简单，在分支置入Tryton支架后可以在主支置入任何药物洗脱支架；不足之处在于它不是必要时支架术，这意味着不得不置入两个支架。

几乎所有的冠脉分叉病变病例都要进行对吻球囊扩张术，其良好效果已得到证实，可有效降低分支血管的狭窄率。对吻球囊扩张术将成为常规方法，因为冠脉病变是慢性疾病，患者可能在5年甚至10年后才复诊，届时若想再治疗分支血管前方的旁路就很困难了，这也是为何我们在术程最后总要打开血管。

SYNTAX研究对临床实践的影响

SYNTAX研究是迄今为止最大的临床试验之一。其结果已经影响了我的临床实践，尤其是被用于或应被用于所有导管室复杂病变的SYNAX评分。SYNAX评分较低或中等的三支血管病变或左主干病变，PCI可替代外科治疗，而SYNAX评分高的冠脉病变，外科手术效果更好。SYNTAX研究另一个重大影响是，虽未达到主要终点，但研究结果使得某些特定的左主干病变患者能够选择PCI治疗，当然这也尚需新的试验验证，并进一步改变指南。

SYNTAX研究对各国家的影响可能最后都是一致的，单就左主干病变研究而言可能对美国尤为重要，因为美国左主干病变指南对PCI治疗的推荐仅为三级推荐，意味着不推荐使用。因此，该研究对美国的影响可能更大。

SYNTAX研究结果显示，对三支病变血管病变，当病变非常复杂时，外科手术治疗效果更好。当病变不那么复杂时，可以考虑以PCI替代。合并糖尿病的三支血管病变患者的治疗选择尚需进行更多研究来明确。从安全性角度来讲，SYNAX评分低和中等的患者PCI治疗是安全的，复杂病变则必须选择外科手术治疗。但可以肯定的是，以后的试验必须对患者进行更好的分层，譬如对糖尿病患者应有一个专门的大型试验。另外左主支<