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Zuin M, Chatzizisis YS, Beier S, Shen C, Colombo A, Rigatelli G. Role of secondary flows in coronary artery bifurcations before and after stenting: What is known so far? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 55:83-87. [PMID: 37385893 DOI: 10.1016/j.carrev.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
Coronary arteries are uniformly exposed to traditional cardiovascular risk factors. However, atherosclerotic lesions occur in preferential regions of the coronary tree, especially in areas with disturbed local blood flow, such as coronary bifurcations. Over the latest years, secondary flows have been linked to the inception and progression of atherosclerosis. Most of these novel findings have been obtained in the field of computational fluid dynamic (CFD) analysis and biomechanics but remain poorly understood by cardiovascular interventionalists, despite the important impact that they may have in clinical practice. We aimed to summarize the current available data regarding the pathophysiological role of secondary flows in coronary artery bifurcation, providing an interpretation of these findings from an interventional perspective.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | | | - Susann Beier
- School of Mechanical and Manufacturing Engineering, UNSW, Sydney, NSW 2053, Australia
| | - Chi Shen
- School of Mechanical and Manufacturing Engineering, UNSW, Sydney, NSW 2053, Australia
| | - Andrea Colombo
- School of Mechanical and Manufacturing Engineering, UNSW, Sydney, NSW 2053, Australia
| | - Gianluca Rigatelli
- Interventional Cardiology, Department of Cardiology, Aulss6 Euganea, Ospedali Riuniti Padova Sud, Monselice, Italy
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Gunawardena TD, Corballis N, Merinopoulos I, Wickramarachchi U, Reinhold J, Maart C, Sreekumar S, Sawh C, Wistow T, Sarev T, Ryding A, Gilbert TJ, Clark A, Vassiliou VS, Eccleshall S. Drug-Coated Balloon vs. Drug-Eluting Stents for De Novo Unprotected Left Main Stem Disease: The SPARTAN-LMS Study. J Cardiovasc Dev Dis 2023; 10:jcdd10020084. [PMID: 36826580 PMCID: PMC9963161 DOI: 10.3390/jcdd10020084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
The objective of this study is to compare the outcomes of patients treated with drug-coated balloons (DCBs) or second-generation drug-eluting stents (DESs) for de novo unprotected left main stem (LMS) disease. Previous studies comparing the treatment of LMS disease suggest that the mortality for DES PCI is not worse than CABG. There are limited data from studies investigating the treatment of de novo LMS disease with DCB angioplasty. We compared the all-cause and cardiac mortality of patients treated with paclitaxel DCB to those with second-generation DES for de novo LMS disease from July 2014 to November 2019. Data were analysed using Kaplan-Meier analyses and propensity-matched analyses. A total of 148 patients were treated with either a DCB or DES strategy. There was no significant difference in all-cause mortality in the DCB group (19.5%) compared to the DES group (15.9%) (HR 1.42 [0.61-3.32], p = 0.42). Regarding cardiac mortality, 2 (4.9%) were recorded for the DCB group and 7 (6.5%) for the DES group (HR 1.21 [0.31-4.67], p = 0.786); for target vessel myocardial infarction, there were 0 (0%) for the DCB group and 7 (6.5%) for the DES group; and for target lesion revascularisation, there were 3 (7.3%) in the DCB group and 9 (8.3%) in the DES group (HR: 0.89 [0.24-3.30]). p = 0.86. These remained not significant after propensity score matching. We found no difference in the mortality outcomes with DCB angioplasty compared to second-generation DES, with a median follow-up of 33 months. DCB can therefore be regarded as a safe option in the treatment of LMS disease in suitable patients.
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Affiliation(s)
- Tharusha D. Gunawardena
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Natasha Corballis
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Correspondence: (N.C.); (V.S.V.)
| | - Ioannis Merinopoulos
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Upul Wickramarachchi
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Johannes Reinhold
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Clint Maart
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Sulfi Sreekumar
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Chris Sawh
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Trevor Wistow
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Toomas Sarev
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Alisdair Ryding
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Tim J. Gilbert
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Vassilios S. Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Royal Brompton Hospital, London SW3 6NP, UK
- Correspondence: (N.C.); (V.S.V.)
| | - Simon Eccleshall
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
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Mohamed MO, Lamellas P, Roguin A, Oemrawsingh RM, Ijsselmuiden AJJ, Routledge H, van Leeuwen F, Debrus R, Roffi M, Mamas MA. Clinical Outcomes of Percutaneous Coronary Intervention for Bifurcation Lesions According to Medina Classification. J Am Heart Assoc 2022; 11:e025459. [PMID: 36000428 PMCID: PMC9496427 DOI: 10.1161/jaha.122.025459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Coronary bifurcation lesions (CBLs) are frequently encountered in clinical practice and are associated with worse outcomes after percutaneous coronary intervention. However, there are limited data around the prognostic impact of different CBL distributions. Methods and Results All CBL percutaneous coronary intervention procedures from the prospective e‐Ultimaster (Prospective, Single‐Arm, Multi Centre Observations Ultimaster Des Registry) multicenter international registry were analyzed according to CBL distribution as defined by the Medina classification. Cox proportional hazards models were used to compare the hazard ratio (HR) of the primary outcome, 1‐year target lesion failure (composite of cardiac death, target vessel–related myocardial infarction, and clinically driven target lesion revascularization), and its individual components between Medina subtypes using Medina 1.0.0 as the reference category. A total of 4003 CBL procedures were included. The most prevalent Medina subtypes were 1.1.1 (35.5%) and 1.1.0 (26.8%), whereas the least prevalent was 0.0.1 (3.5%). Overall, there were no significant differences in patient and procedural characteristics among Medina subtypes. Only Medina 1.1.1 and 0.0.1 subtypes were associated with increased target lesion failure (HR, 2.6 [95% CI, 1.3–5.5] and HR, 4.0 [95% CI, 1.6–9.0], respectively) at 1 year, compared with Medina 1.0.0, prompted by clinically driven target lesion revascularization (HR, 3.1 [95% CI, 1.1–8.6] and HR, 4.6 [95% CI, 1.3–16.0], respectively) as well as cardiac death in Medina 0.0.1 (HR, 4.7 [95% CI, 1.0–21.6]). No differences in secondary outcomes were observed between Medina subtypes. Conclusions In a large multicenter registry analysis of coronary bifurcation percutaneous coronary intervention procedures, we demonstrate prognostic differences in 1‐year outcomes between different CBL distributions, with Medina 1.1.1 and 0.0.1 subtypes associated with an increased risk of target lesion failure.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences Keele University Newcastle United Kingdom.,Institute of Health Informatics University College London London United Kingdom
| | - Pablo Lamellas
- Department of Interventional Cardiology and Endovascular Therapeutics Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina
| | - Ariel Roguin
- Department of Cardiology Hillel Yaffe Medical Center Hadera Israel
| | | | | | | | | | - Roxane Debrus
- Medical and Clinical Division Terumo Europe NV Leuven Belgium
| | - Marco Roffi
- Division of Cardiology University Hospitals Geneva Switzerland
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences Keele University Newcastle United Kingdom
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Kovacevic M, Burzotta F, Elharty S, Besis G, Aurigemma C, Romagnoli E, Trani C. Left Main Trifurcation and Its Percutaneous Treatment: What Is Known So Far? Circ Cardiovasc Interv 2021; 14:e009872. [PMID: 33685210 DOI: 10.1161/circinterventions.120.009872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In humans, the most common anatomic variation of the left main (LM) stem is represented by its distal division in 3 branches (LM trifurcation) instead of 2. LM trifurcation disease accounts for ≈10% to 15% of all LM diseases and is often managed by cardiac surgery. Over the last decades, due to the improvement of interventional material and techniques, percutaneous coronary intervention started gaining acceptance to treat patients with LM disease including those with trifurcated anatomy. Yet, LM trifurcation stenosis with its intrinsic anatomic complexity (3 branches, at least 4 angles, wide variability in branch size and disease) is recognized as a challenging lesion subset for percutaneous coronary intervention. In this review, we summarize available data about LM trifurcation anatomy, its influence on percutaneous coronary intervention feasibility, and the evidence collected regarding the different technical options (including trissing balloon inflation).
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Affiliation(s)
- Mila Kovacevic
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.).,Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy (M.K., F.B., S.E., G.B., C.T.)
| | - Francesco Burzotta
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.).,Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy (M.K., F.B., S.E., G.B., C.T.)
| | - Sameh Elharty
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.).,Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy (M.K., F.B., S.E., G.B., C.T.)
| | - George Besis
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.).,Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy (M.K., F.B., S.E., G.B., C.T.)
| | - Cristina Aurigemma
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.)
| | - Enrico Romagnoli
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.)
| | - Carlo Trani
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (M.K., F.B., S.E., G.B., C.A., E.R., C.T.).,Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy (M.K., F.B., S.E., G.B., C.T.)
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Raphael CE, O'Kane PD. Contemporary approaches to bifurcation stenting. JRSM Cardiovasc Dis 2021; 10:2048004021992190. [PMID: 33717470 PMCID: PMC7917419 DOI: 10.1177/2048004021992190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/19/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
Bifurcation lesions are common and associated with higher risks of major cardiac events and restenosis after percutaneous coronary intervention (PCI). Treatment requires understanding of lesion characteristics, stent design and therapeutic options. We review the evidence for provisional vs 2-stent techniques. We conclude that provisional stenting is suitable for most bifurcation lesions. We detail situations where a 2-stent technique should be considered and the steps for performing each of the 2-step techniques. We review the importance of lesion preparation, intracoronary imaging, proximal optimization (POT) and kissing balloon inflation.
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