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Zhang JJ, Ye F, Xu K, Kan J, Tao L, Santoso T, Munawar M, Tresukosol D, Li L, Sheiban I, Li F, Tian NL, Rodríguez AE, Paiboon C, Lavarra F, Lu S, Vichairuangthum K, Zeng H, Chen L, Zhang R, Ding S, Gao F, Jin Z, Hong L, Ma L, Wen S, Wu X, Yang S, Yin WH, Zhang J, Wang Y, Zheng Y, Zhou L, Zhou L, Zhu Y, Xu T, Wang X, Qu H, Tian Y, Lin S, Liu L, Lu Q, Li Q, Li B, Jiang Q, Han L, Gan G, Yu M, Pan D, Shang Z, Zhao Y, Liu Z, Yuan Y, Chen C, Stone GW, Han Y, Chen SL. Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. Eur Heart J 2021; 41:2523-2536. [PMID: 32588060 DOI: 10.1093/eurheartj/ehaa543] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/28/2020] [Accepted: 06/12/2020] [Indexed: 12/29/2022] Open
Abstract
AIM The present study aimed to assess the benefits of two-stent techniques for patients with DEFINITION criteria-defined complex coronary bifurcation lesions. METHODS AND RESULTS In total, 653 patients with complex bifurcation lesions at 49 international centres were randomly assigned to undergo the systematic two-stent technique (two-stent group) or provisional stenting (provisional group). The primary endpoint was the composite of target lesion failure (TLF) at the 1-year follow-up, including cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (TLR). The safety endpoint was definite or probable stent thrombosis. At the 1-year follow-up, TLF occurred in 37 (11.4%) and 20 (6.1%) patients in the provisional and two-stent groups, respectively [77.8%: double-kissing crush; hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.30-0.90; P = 0.019], largely driven by increased TVMI (7.1%, HR 0.43, 95% CI 0.20-0.90; P = 0.025) and clinically driven TLR (5.5%, HR 0.43, 95% CI 0.19-1.00; P = 0.049) in the provisional group. At the 1 year after indexed procedures, the incidence of cardiac death was 2.5% in the provisional group, non-significant to 2.1% in the two-stent group (HR 0.86, 95% CI 0.31-2.37; P = 0.772). CONCLUSION For DEFINITION criteria-defined complex coronary bifurcation lesions, the systematic two-stent approach was associated with a significant improvement in clinical outcomes compared with the provisional stenting approach. Further study is urgently warranted to identify the mechanisms contributing to the increased rate of TVMI after provisional stenting. STUDY REGISTRATION http://www.clinicaltrials.com; Identifier: NCT02284750.
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Affiliation(s)
- Jun-Jie Zhang
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing 210006, China
| | - Fei Ye
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing 210006, China
| | - Kai Xu
- Division of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Kan
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing 210006, China
| | - Ling Tao
- Division of Cardiology, Xijing Hospital, 4th Military Medical University, Xi'an, China
| | - Teguh Santoso
- Division of Cardiology, Medistra Hospital, University of Indonesia Medical School, Jakarta, Indonesia
| | - Muhammad Munawar
- Division of Cardiology, Binawaluya Cardiac Center, Jakarta, Indonesia
| | - Damras Tresukosol
- Division of Cardiology, Medicine Siriraj Hospital, Bangkok, Thailand
| | - Li Li
- Division of Cardiology, Guangzhou Red Cross Hospital, Guangzhou, China
| | - Imad Sheiban
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - Feng Li
- Division of Cardiology, Oriental General Hospital, Huainan, China
| | - Nai-Liang Tian
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | | | | | - Francesco Lavarra
- Division of Cardiology, Jilin Cardiovascular Hospital, Changchun, China
| | - Shu Lu
- Division of Cardiology, Taicang 1st People's Hospital, Taicang, China
| | | | - Hesong Zeng
- Division of Cardiology, Wuhan Tongji Hospital, United Medical University, Wuhan, China
| | - Lianglong Chen
- Division of Cardiology, Fujian Medical University Union Hospital, Fujian Institute of Coronary Artery Disease, Fujian Heart Medical Center, Fuzhou, China
| | - Ruiyan Zhang
- Division of Cardiology, Shanghai Ruijin Hospital, Shanghai Communication University, Shanghai, China
| | - Shiqin Ding
- Division of Cardiology, Xinhua Hospital, Huainan, China
| | - Fengtang Gao
- Division of Cardiology, Gansu Provincial People's Hospital, Lanzhou, China
| | - Zening Jin
- Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lang Hong
- Division of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Likun Ma
- Division of Cardiology, Anhui Provincial Hospital, Hefei, China
| | - Shangyu Wen
- Division of Cardiology, Tianjin 4th Central Hospital, Tianjin, China
| | - Xueming Wu
- Division of Cardiology, Wuxi 3rd People's Hospital, Wuxi, China
| | - Song Yang
- Division of Cardiology, Yixing People's Hospital, Yixing, China
| | - Wei-Hsian Yin
- Division of Cardiology, Cheng-Hsin General Hospital, Taipei, China
| | - Jun Zhang
- Division of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Yan Wang
- Division of Cardiology, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Yonghong Zheng
- Division of Cardiology, Jintan Traditional Chinese Medicine Hospital, Jintan, China
| | - Lei Zhou
- Division of Cardiology, Liyang Hospital of Traditional Chinese Medicine, Liyang, China
| | - Limin Zhou
- Division of Cardiology, Chuzhou People's Hospital, Chuzhou, China
| | - Yuansheng Zhu
- Division of Cardiology, Huaian 2nd People's Hospital, Huaian, China
| | - Tan Xu
- Division of Cardiology, Xinyang Central Hospital, Xinyang, China
| | - Xin Wang
- Division of Cardiology, Lianyungang Traditional Chinese Medicine Hospital, Lianyungang, China
| | - Hong Qu
- Division of Cardiology, XuanCheng Central Hospital, Xuancheng, China
| | - Yulong Tian
- Division of Cardiology, Xuyi People's Hospital, Xuyi, China
| | - Song Lin
- Division of Cardiology, Jintan People's Hospital, Jintan, China
| | - Lijun Liu
- Division of Cardiology, Huainan People's Hospital, Huainan, China
| | - Qinghua Lu
- Division of Cardiology, 2nd People's Hospital, Shandong University, Jinan, China
| | - Qihua Li
- Division of Cardiology, Changzhou Traditional Chinese Medicine Hospital, China
| | - Bo Li
- Division of Cardiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Qing Jiang
- Division of Cardiology, Anqing 1st People's Hospital, Anqing, China
| | - Leng Han
- Division of Cardiology, Changshu People's Hospital, Changshu, China
| | - Guojun Gan
- Division of Cardiology, 17th Metallurgical Hospital, Maanshan, China
| | - Mengyue Yu
- Division of Cardiology, Qingdao Campus of Fuwai Hospital, Qingdao, China
| | - Defeng Pan
- Division of Cardiology, Xuzhou 2nd People's Hospital, Xuzhou, China
| | - Zhenglu Shang
- Division of Cardiology, Wuxi Huishan District People's Hospital, Wuxi, China
| | - Yanfang Zhao
- Division of Cardiology, Nanjing 81 Hospital, Nanjing, China
| | - Zhizhong Liu
- Division of Cardiology, Hongze People's Hospital, Huai'an, China
| | - Ye Yuan
- Trinity College, University of Toronto, Toronto, Canada
| | - Cynthia Chen
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Ican School of Medicine at Mount Sinai, New York, NY, USA and The Cardiovascular Research Foundation, New York, NY, USA
| | - Yaling Han
- Division of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing 210006, China.,College of Pharmacy, Nanjing Medical University, Nanjing, China
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2
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Li X, Kan J, She L, Shrestha R, Pan T, You W, Wu Z, Ge Z, Zhang JJ, Gogas BD, Ye F, Chen SL. Optical coherence tomography predictors of target vessel myocardial infarction after provisional stenting in patients with coronary bifurcation disease. Catheter Cardiovasc Interv 2020; 97:1331-1340. [PMID: 32659048 DOI: 10.1002/ccd.28980] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/23/2020] [Accepted: 05/06/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Provisional side branch (SB) stenting is correlated with target vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the mechanisms underlying this association remain unknown. OBJECTIVES To determine the correlation between SB lesion length with vulnerable plaques and TVMI using optical coherence tomography (OCT). BACKGROUND The correlation between SB lesion length with vulnerable plaques and TVMI is unknown. METHODS A total of 405 patients with 405 bifurcation lesions who underwent preprocedure OCT imaging of both the main vessel (MV) and the SB were enrolled. Patients were divided into long SB lesion (SB lesion length ≥10 mm) and short SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis; they were also stratified by the presence of vulnerable plaques identified by OCT. The primary endpoint was the occurrence of TVMI after provisional stenting at 1-year follow-up. RESULTS In total, 178 (43.9%) patients had long SB lesions. Vulnerable plaques were predominantly localized in the MV and were more frequently in the long SB lesion group (42.7%) than in the short SB lesion group (24.2%, p < .001). At 1-year follow-up after provisional stenting, there were 31 (7.7%) TVMIs, with 21 (11.8%) in the long SB lesion group and 10 (4.4%) in the short SB lesion group (p = .009). Multivariate regression analysis showed that long SB lesion length (p = .011), absence of vulnerable plaques in the polygon of confluence (p = .001), and true coronary bifurcation lesions (p = .004) were the three independent factors of TVMI. CONCLUSIONS The presence of long SB lesion with MV vulnerable plaques predicts the increased risk of TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further studies are warranted to identify the best stenting techniques for coronary bifurcation lesions with long SB lesions.
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Affiliation(s)
- Xiaobo Li
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jing Kan
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Liping She
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Rajiv Shrestha
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tao Pan
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Wei You
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhiming Wu
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhen Ge
- Division of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Jun-Jie Zhang
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bill D Gogas
- Division of Cardiology, Emory University Hospital, Atlanta, Georgia, USA
| | - Fei Ye
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Division of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,College of Pharmacy, Nanjing Medical University, Nanjing, China
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Pagiatakis C, Tardif JC, L'Allier PL, Mongrain R. Effect of stenosis eccentricity on the functionality of coronary bifurcation lesions-a numerical study. Med Biol Eng Comput 2017; 55:2079-2095. [PMID: 28500478 DOI: 10.1007/s11517-017-1653-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 04/25/2017] [Indexed: 01/10/2023]
Abstract
Interventional cardiologists still rely heavily on angiography for the evaluation of coronary lesion severity, despite its poor correlation with the presence of ischemia. In order to improve the accuracy of the current diagnostic procedures, an understanding of the relative influence of geometric characteristics on the induction of ischemia is required. This idea is especially important for coronary bifurcation lesions (CBLs), whose treatment is complex and is associated with high rates of peri- and post-procedural clinical events. Overall, it is unclear which geometric and morphological parameters of CBLs influence the onset of ischemia. More specifically, the effect of stenosis eccentricity is unknown. Computational fluid dynamic simulations, under a geometric multiscale framework, were executed for seven CBL configurations within the left main coronary artery bifurcation. Both concentric and eccentric stenosis profiles of mild to severe constriction were considered. By using a geometric multiscale framework, the fractional flow reserve, which is the gold-standard clinical diagnostic index, could be calculated and was compared between the eccentric and concentric profiles for each case. The results suggested that for configurations where the supplying vessel is stenosed, eccentricity could have a notable effect on and therefore be an important factor that influences configuration functionality.
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Affiliation(s)
- Catherine Pagiatakis
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West, Montreal, Quebec, H3A 0C3, Canada. .,Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada.
| | - Jean-Claude Tardif
- Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada.,Faculty of Medicine, Université de Montréal - Pavillon Roger-Gaudry, 2900 Edouard-Montpetit Boulevard, Montreal, Quebec, H3T 1J4, Canada
| | - Philippe L L'Allier
- Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada.,Faculty of Medicine, Université de Montréal - Pavillon Roger-Gaudry, 2900 Edouard-Montpetit Boulevard, Montreal, Quebec, H3T 1J4, Canada
| | - Rosaire Mongrain
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West, Montreal, Quebec, H3A 0C3, Canada.,Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
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Insights into the spatial distribution of lipid-rich plaques in relation to coronary artery bifurcations. Coron Artery Dis 2015; 26:133-41. [DOI: 10.1097/mca.0000000000000188] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Caglar IM, Demir B, Caglar FNT, Vural A, Ugurlucan M, Ciftci S, Ungan I, Gedikbasi A, Dasli T, Karakaya O. Contrast Layering. Angiology 2014; 66:136-42. [DOI: 10.1177/0003319714520955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with angiographically normal coronary arteries sometimes exhibit delayed clearance of contrast medium. This contrast layering (CL) was tested with intravascular ultrasound (IVUS) and markers of endothelial dysfunction and oxidative stress. The study group (n = 26) consisted of patients with CL and the control group (n = 32) comprised patients with normal coronary arteries despite angina symptoms. The CL was observed in 36 coronary arteries of 26 patients in the study group. Total antioxidant status and nitric oxide levels were significantly lower; total oxidant status, malondialdehyde plasma levels, and oxidative stress index were significantly higher in patients with CL than in controls. The IVUS studies revealed that atherosclerotic plaque burden, fibrous tissue, dense calcific tissue, and necrotic core ratios were significantly higher in the coronary segments with CL compared with adjacent normal segments. These results support the concept of CL as a new angiographic appearance of early atherosclerosis.
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Affiliation(s)
- Ilker Murat Caglar
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Bulent Demir
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | | | - Alper Vural
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Serkan Ciftci
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Ismail Ungan
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Asuman Gedikbasi
- Department of Clinical Biochemistry, Bakirkoy Dr. Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Tolga Dasli
- Department of Cardiology, Kocaeli Derince Research and Education Hospital, Kocaeli, Turkey
| | - Osman Karakaya
- Department of Cardiology, Bakirkoy Dr Sadi Konuk Research and Education Hospital, Istanbul, Turkey
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6
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Comparison of lipid deposition at coronary bifurcations versus at nonbifurcation portions of coronary arteries as determined by near-infrared spectroscopy. Am J Cardiol 2013; 112:369-72. [PMID: 23642506 DOI: 10.1016/j.amjcard.2013.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/24/2013] [Accepted: 03/24/2013] [Indexed: 11/21/2022]
Abstract
Atherosclerosis has been shown to develop preferentially at sites of coronary bifurcation, yet culprit lesions resulting in ST-elevation myocardial infarction do not occur more frequently at these sites. We hypothesized that these findings can be explained by similarities in intracoronary lipid and that lipid and lipid core plaque would be found with similar frequency in coronary bifurcation and nonbifurcation segments. One hundred seventy bifurcations were identified, 156 of which had comparative nonbifurcation segments proximal and/or distal to the bifurcation. We compared lipid deposition at bifurcation and nonbifurcation segments in coronary arteries using near-infrared spectroscopy (NIRS), a novel method for the in vivo detection of coronary lipid. Any NIRS signal for the presence of lipid was found with similar frequency in bifurcation and nonbifurcation segments (79% vs 74%, p = NS). Lipid core burden index, a measure of total lipid quantity indexed to segment length, was similar across bifurcation segments as well as their proximal and distal controls (lipid core burden index 66.3 ± 106, 67.1 ± 116, and 66.6 ± 104, p = NS). Lipid core plaque, identified as a high-intensity focal NIRS signal, was found in 21% of bifurcation segments, and 20% of distal nonbifurcation segments (p = NS). In conclusion, coronary bifurcations do not appear to have higher levels of intracoronary lipid or lipid core plaque than their comparative nonbifurcation regions.
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Shang Y, Mintz GS, Pu J, Guo J, Kobayashi N, Franklin-Bond T, Leon MB, Moses JW, Maehara A, Shimizu T, Yakushiji T. Bypass to the left coronary artery system may accelerate left main coronary artery negative remodeling and calcification. Clin Res Cardiol 2013; 102:831-5. [DOI: 10.1007/s00392-013-0598-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 07/16/2013] [Indexed: 10/26/2022]
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8
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Schoenenberger AW, Urbanek N, Toggweiler S, Stuck AE, Resink TJ, Erne P. Ultrasound-assessed non-culprit and culprit coronary vessels differ by age and gender. World J Cardiol 2013; 5:42-48. [PMID: 23539636 PMCID: PMC3610005 DOI: 10.4330/wjc.v5.i3.42] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/05/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate age- and gender-related differences in non-culprit versus culprit coronary vessels assessed with virtual histology intravascular ultrasound (VH-IVUS).
METHODS: In 390 patients referred for coronary angiography to a single center (Luzerner Kantonsspital, Switzerland) between May 2007 and January 2011, 691 proximal vessel segments in left anterior descending, circumflex and/or right coronary arteries were imaged by VH-IVUS. Plaque burden and plaque composition (fibrous, fibro-fatty, necrotic core and dense calcium volumes) were analyzed in 3 age tertiles, according to gender and separated for vessels containing non-culprit or culprit lesions. To classify as vessel containing a culprit lesion, the patient had to present with an acute coronary syndrome, and the VH-IVUS had to be performed in a vessel segment containing the culprit lesion according to conventional coronary angiography.
RESULTS: In non-culprit vessels the plaque burden increased significantly with aging (in men from 37% ± 12% in the lowest to 46% ± 10% in the highest age tertile, P < 0.001; in women from 30% ± 9% to 40% ± 11%, P < 0.001); men had higher plaque burden than women at any age (P < 0.001 for each of the 3 age tertiles). In culprit vessels of the lowest age tertile, plaque burden was significantly higher than that in non-culprit vessels (in men 48% ± 6%, P < 0.001 as compared to non-culprit vessels; in women 44% ± 18%, P = 0.004 as compared to non-culprit vessels). Plaque burden of culprit vessels did not significantly change during aging (plaque burden in men of the highest age tertile 51% ± 9%, P = 0.523 as compared to lowest age tertile; in women of the highest age tertile 49% ± 8%, P = 0.449 as compared to lowest age tertile). In men, plaque morphology of culprit vessels became increasingly rupture-prone during aging (increasing percentages of necrotic core and dense calcium), whereas plaque morphology in non-culprit vessels was less rupture-prone and remained constant during aging. In women, necrotic core in non-culprit vessels was very low at young age, but increased during aging resulting in a plaque morphology that was very similar to men. Plaque morphology in culprit vessels of young women and men was similar.
CONCLUSION: This study provides evidence that age- and gender-related differences in plaque burden and plaque composition significantly depend on whether the vessel contained a non-culprit or culprit lesion.
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9
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Schoenenberger AW, Urbanek N, Bergner M, Toggweiler S, Resink TJ, Erne P. Associations of reactive hyperemia index and intravascular ultrasound-assessed coronary plaque morphology in patients with coronary artery disease. Am J Cardiol 2012; 109:1711-6. [PMID: 22440130 DOI: 10.1016/j.amjcard.2012.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 02/07/2012] [Accepted: 02/07/2012] [Indexed: 12/15/2022]
Abstract
Although reactive hyperemia index (RHI) predicts future coronary events, associations with intravascular ultrasound (IVUS)-assessed coronary plaque structure have not been reported. This study therefore investigated associations between RHI and IVUS-assessed coronary plaques. In 362 patients RHI was measured by noninvasive peripheral arterial tonometry and coronary plaque components (fibrous, fibrofatty, necrotic core, and dense calcium) were identified by IVUS in 594 vessel segments of the left anterior descending, circumflex, and/or right coronary arteries. RHI values <1.67 were considered abnormal. Analysis of variance was used to detect independent associations between RHI and plaque composition. Patients with an abnormal RHI had greater plaque burden (41% vs 39% in patients with normal RHI, p = 0.047). Compared to patients with normal RHI, plaque of patients with abnormal RHI had more necrotic core (21% vs 17%, p <0.001) and dense calcium (19% vs 15%, p <0.001) and less fibrous (49% vs 54%, p <0.001) and fibrofatty (11% vs 14%, p = 0.002) tissue. After adjustment for age, gender, cardiovascular risk factors, and drug therapy, abnormal RHI remained significantly associated with fibrous (F ratio 14.79, p <0.001), fibrofatty (F ratio 5.66, p = 0.018), necrotic core (F ratio 14.47, p <0.001), and dense calcium (F ratio 10.80, p = 0.001) volumes. In conclusion, coronary artery plaques of patients with abnormal RHI had a larger proportion of necrotic core and dense calcium. The association of an abnormal RHI with a plaque structure that is more prone to rupture may explain why these patients exhibit a greater risk of coronary events.
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10
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Schoenenberger AW, Urbanek N, Toggweiler S, Seelos R, Jamshidi P, Resink TJ, Erne P. Deviation from Murray's law is associated with a higher degree of calcification in coronary bifurcations. Atherosclerosis 2012; 221:124-30. [PMID: 22261173 DOI: 10.1016/j.atherosclerosis.2011.12.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 12/20/2011] [Accepted: 12/23/2011] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Murray's law describes the optimal branching anatomy of vascular bifurcations. If Murray's law is obeyed, shear stress is constant over the bifurcation. Associations between Murray's law and intravascular ultrasound (IVUS) assessed plaque composition near coronary bifurcations have not been investigated previously. METHODS In 253 patients plaque components (fibrous, fibro-fatty, necrotic core, and dense calcium) were identified by IVUS in segments proximal and distal to the bifurcation of a coronary side branch. The ratio of mother to daughter vessels was calculated according to Murray's law (Murray ratio) with a high Murray ratio indicating low shear stress. Analysis of variance was used to detect independent associations of Murray ratio and plaque composition. RESULTS Patients with a high Murray ratio exhibited a higher relative amount of dense calcium and a lower amount of fibrous and fibro-fatty tissue than those with a low Murray ratio. After adjustment for age, sex, cardiovascular risk factors or concomitant medications, the Murray ratio remained significantly associated with fibrous volume distal (F-ratio 4.90, P=0.028) to the bifurcation, fibro-fatty volume distal (F-ratio 4.76, P=0.030) to the bifurcation, and dense calcium volume proximal (F-ratio 5.93, P=0.016) and distal (F-ratio 5.16, P=0.024) to the bifurcation. CONCLUSION This study shows that deviation from Murray's law is associated with a high degree of calcification near coronary bifurcations. Individual deviations from Murray's law may explain why some patients are prone to plaque formation near vessel bifurcations.
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Affiliation(s)
- Andreas W Schoenenberger
- Division of Geriatrics, Department of General Internal Medicine, Inselspital, Bern University Hospital, Switzerland
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11
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Giannoglou GD, Antoniadis AP, Koskinas KC, Chatzizisis YS. Flow and atherosclerosis in coronary bifurcations. EUROINTERVENTION 2011; 6 Suppl J:J16-23. [PMID: 21930484 DOI: 10.4244/eijv6supja4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Coronary bifurcations are among the most frequent sites affected by atherosclerosis. In these regions, complex haemodynamic conditions prevail and local flow disturbances dictate the localisation and progression of atheroma. Endothelial shear stress (ESS) is the main flow-related factor affecting the distribution of atherosclerosis in a bifurcation. Plaques are more prevalent in low ESS areas, such as the lateral walls of the main vessel and side branches, while they are less common in the flow divider or carina, which is characterised by high ESS. However, the carina is not free of atheroma and is affected in up to one third of cases, but never in isolation. Lesions in the carina are likely to develop at a later stage of atherosclerosis, as result of circumferential expansion of plaques from the lateral wall. Pulsatile flow augments the local atherogenic environment by inducing low and oscillatory ESS. The geometrical configuration is also important as increased curvature and wide angles between the side branches of the bifurcation intensify flow perturbations, and highly curved segments show low ESS in the inner aspect of curvatures. Further research on the flow conditions which determine the initiation and progression of atherosclerosis in bifurcations will allow for more efficient prevention and management strategies.
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Affiliation(s)
- George D Giannoglou
- Cardiovascular Engineering and Atherosclerosis Laboratory, 1st Cardiology Department, AHEPA University General Hospital, Aristotle University Medical School, 1 St. Kyriakidi Street, Thessaloniki, Greece
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