Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial

Comparison between provisional and dual systematic stenting approach for left main bifurcation disease: A systematic review and meta-analysis

Despite recent advancements, challenges persist in determining the optimal stenting strategy for LM bifurcation disease. Hence, this systematic review aims to compare single provisional and systematic dual stenting for managing LM bifurcation disease. A systematic search was performed until January 14, 2024. For the effect measure, risk ratios (RRs) was calculated. This study included 22 studies with 10776 participants. The all-cause mortality and cardiovascular mortality revealed comparable outcomes between provisional and dual-systematic stenting (RR 1.13, CI95 %: 0.87-1.47, p 0.36, I2 59 %; RR 1.16, CI95 %: 0.73-1.84, p 0.63, I2 80 %). In addition, MACE, MI, TLR, TVR, and in stent thrombosis also showed similar findings. Subgroup analysis revealed that cohort studies was the source of heterogeneity in all-cause mortality, stent thrombosis, and TLR. This meta-analysis suggests comparable outcomes between provisional and dual-systematic stenting in managing LM bifurcation disease. Further study is needed to validate the outcomes of novel techniques.

BOOM: A novel bifurcation stent technique using optical coherence tomography co-registration

BACKGROUND/PURPOSE

Bifurcation lesions comprise 20 % of percutaneous coronary interventions (PCI) and are associated with worse long-term outcomes. With an increasing percentage of patients presenting with complex anatomy, including bifurcation disease, there is a need for treatment strategies to optimize PCI outcomes.

METHODS/MATERIALS

We retrospectively analyzed 48 patients undergoing OCT guided bifurcation PCI using the 'Bifurcation and Ostial OCT Mapping' (BOOM) technique. The primary efficacy variable studied was stent precision following deployment, defined as the distance of the most proximal stent strut from the true ostium of the target vessel. Additionally, targeted follow-up occurred by phone at 6- and 12-months post procedure, where the frequency of myocardial infarction, target lesion revascularization, target vessel and non-target vessel revascularization, and mortality were collected.

RESULTS

A total of 40 (83.3 %) had an ostial lesion that required treatment while the remaining patients had true bifurcation disease. Most target lesions were in either the LAD or its branches (29 lesions (60.3 %)). With respect to stent positioning, the median absolute geographic miss, (i.e., stent protrusion into the main branch or lack of complete ostial stent coverage), was 0.75 mm. At 6 months, one patient required target lesion revascularization with no additional patients at 12 months.

CONCLUSIONS

BOOM is a safe and simple strategy that can be a useful technique to optimize precise stent placement for ostial and bifurcation lesions.

Intravascular Ultrasound vs Angiography-Guided Drug-Coated Balloon Angioplasty: The ULTIMATE Ⅲ Trial

BACKGROUND

Drug-coated balloon (DCB) angioplasty seems a safe and effective option for specific de novo coronary lesions. However, the beneficial effect of intravascular ultrasound (IVUS)-guided DCB angioplasty in de novo lesions remains uncertain.

OBJECTIVES

This study aimed to assess the benefits of IVUS guidance over angiography guidance during DCB angioplasty in de novo coronary lesions.

METHODS

A total of 260 patients with high bleeding risk who had a de novo coronary lesion (reference vessel diameter 2.0-4.0 mm, and lesion length ≤15 mm) were randomly assigned to either an IVUS-guided or an angioplasty-guided DCB angioplasty group. The primary endpoint was in-segment late lumen loss (LLL) at 7 months after procedure. The secondary endpoint was target vessel failure at 6 months.

RESULTS

A total of 2 patients in the angiography-guided group and 7 patients in the IVUS-guided group underwent bailout stent implantation (P = 0.172). The primary endpoint of 7-month LLL was 0.03 ± 0.52 mm with angiography guidance vs -0.10 ± 0.34 mm with IVUS guidance (mean difference 0.14 mm; 95% CI: 0.02-0.26; P = 0.025). IVUS guidance was also associated with a larger 7-month minimal lumen diameter (2.06 ± 0.62 mm vs 1.75 ± 0.63 mm; P < 0.001) and a smaller diameter stenosis (28.15% ± 13.88% vs 35.83% ± 17.69%; P = 0.001) compared with angiography guidance. Five target vessel failures occurred at 6 months, with 4 (3.1%) in the angiography-guided group and 1 (0.8%) in the IVUS-guided group (P = 0.370).

CONCLUSIONS

This study demonstrated that IVUS-guided DCB angioplasty is associated with a lower LLL in patients with a de novo coronary lesion compared with angiography guidance. (Intravascular Ultrasound Versus Angiography Guided Drug-Coated Balloon [ULTIMATE-III]; NCT04255043).

Double kiss mini-crush technique to treat complex recurrent renal artery in-stent restenosis

The double-kiss mini-crush (DKMC) technique has been successfully deployed in the past for the treatment of complex coronary lesions even for left main lesions. Our case report consists of a proof-of-principle that the DKMC technique can be successfully translated as well to the field of complex renal artery lesions. Insightful thinking out-of-the "coronary" box in concert with skillful off-label application of coronary stenting procedures may open the gate for unprecedented opportunities for the treatment of difficult-to-tackle in-stent restenosis in the renal circulation.

The impact of the bifurcation angle for the Nano-Crush two-stent coronary bifurcation technique on long-term outcomes in a real-world clinical population

AIM

This study aims to assess the direct impact of bifurcation angle (BA) on immediate procedural outcomes and patient prognosis post-Nano-Crush stenting for coronary bifurcation lesions.

METHODS

A retrospective analysis was conducted for all consecutive patients treated with the Nano-Crush technique across two high-volume interventional centers from January 2020 to October 2022.

PRIMARY ENDPOINT

comparison of target lesion failure rate in two cohorts based on bifurcation angle (<70° vs. ≥70°), with secondary endpoints including side branch ostium coverage, rate of successful final kissing balloon inflation (FKBI), need for conversion to another technique, and procedure length.

RESULTS

Baseline demographics included 71 patients in the BA<70° group and 49 in the BA≥70° group, with well-balanced characteristics. Angiographic characteristics revealed similar trends, including anatomic and morphological lesion characteristics (referencing Syntax score, Medina classification, and presence of calcifications). Both groups predominantly had complex coronary disease, with a baseline mean Syntax score of 24.18 ± 8.19 in the BA<70° group and 23.91 ± 7.29 in the BA≥70° group, respectively. A dedicated debulking device for lesion preparation was used in 25.35 % of patients in the first group and in 28.57 % of patients in the second group. The primary endpoint occurred in 5.63 % of patients in the BA<70° group and in 4.08 % of patients in the BA≥70° group (P = 0.7014) after ≥ 2 years of clinical follow-up. Angiographic success was achieved in 100 % of both groups, with procedural time averaging 74.99 ± 25.55 min in the BA≥70° and 76.94 ± 27.81 min in the BA<70° (P = 0.6922). The rate of successful final kissing balloon inflation was 98.59 % in the BA<70° group and 95.91 % in the BA≥70° group (P = 0.3566). The mean contrast volume was 189.54 ± 73.74 ml in BA<70° and 168.9 ± 62.77 ml in BA≥70° (P = 0.1126). Clinical follow-ups at 30 days and 2 years revealed similar outcomes and complications for each group, as summarized in Table 3.

CONCLUSIONS

Our results demonstrate that the bifurcation angle does not significantly impact long-term clinical outcomes or procedural parameters, such as side branch ostium coverage, conversion to a modified DK Crush technique, FKBI success rate, and procedure length. These findings suggest that the Nano-Crush technique can be a viable option for bifurcation lesions, irrespective of the bifurcation angle, achieving optimal side branch ostium coverage while preventing excessive protrusion into the main vessel.

Clinical outcomes of single- versus two-stent PCI technique in severely calcified true bifurcation lesions after rotational atherectomy

BACKGROUND

Severely calcified coronary bifurcations complicate percutaneous coronary interventions (PCI) and often necessitate dedicated lesion preparation. We compared the outcomes of single- versus two-stent techniques for treating heavily calcified true bifurcation lesions following rotational atherectomy (RA).

METHODS

Among patients receiving RA for severely calcified true bifurcations at a single center, 59 were treated with a single stent, and another 59 received two stents. We analyzed in-hospital adverse outcomes and 1-year rates of the bifurcation-oriented composite endpoint (BOCE), defined as cardiac death, target bifurcation myocardial infarction (TB-MI), or target bifurcation revascularization (TBR).

RESULTS

The single-stent arm was associated with more in-hospital adverse outcomes (adj. OR, 6.13; 95% CI, 1.34-28.0; p = 0.019), driven by higher peri-procedural MI rates (18.6% vs. 5.1%, p = 0.043) and more side branch compromise (13.6% vs. 0%, p = 0.006). After 1 year, both techniques had comparable 1-year BOCE (adj. HR, 0.38; 95% CI, 0.12-1.23; p = 0.106). We observed a significant interaction between the treatment technique and the presence of LM bifurcation (p interaction = 0.012), favoring single-stent technique in patients with non-LM bifurcations (HR 0.14, 95% CI 0.03-0.68; p = 0.015). Notably, the single-stent technique had lower rates of TBR (2% vs. 15%, p log-rank = 0.026) after 1 year.

CONCLUSION

Patients with severely calcified true bifurcation lesions, treated with RA followed by a single stent implantation, had more in-hospital adverse outcomes compared to those treated with two stents. However, the superior outcomes of the two-stent technique did not translate into improved long-term results. In fact, the two-stent technique was even associated with higher rates of revascularization after 1 year.

Cardiovascular outcomes of complex bifurcation lesions following double kissing crush or nano-crush techniques: The multicenter EVOLUTE-CRUSH V study

BACKGROUND

Double kissing crush (DKC) and nano-crush (NC) techniques are frequently used, but the comparison for both techniques is still lacking. The goal of this multicenter study was to retrospectively assess the midterm clinical results of DKC and NC stenting in patients with complex bifurcation lesions (CBLs).

METHODS

A total of 324 consecutive patients [male: 245 (75.6%), mean age: 60.73 ± 10.21 years] who underwent bifurcation percutaneous coronary intervention between January 2019 and May 2023 were included. The primary endpoint defined as the major cardiovascular events (MACE) included cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (TLR). Inverse probability weighting (IPW) was performed to reduce treatment selection bias. This is the first report comparing the clinical outcomes of DKC and NC stenting in patients with CBL.

RESULTS

The initial revascularization strategy was DKC in 216 (66.7%) cases and NC in 108 (33.3%) patients. SYNTAX scores [25.5 ± 6.73 vs. 23.32 ± 6.22, p = 0.005] were notably higher in the NC group than the DKC group. The procedure time (76.98 ± 25.1 vs. 57.5 ± 22.99 min, p = 0.001) was notably higher in the DKC group. The incidence of MACE (18.5 vs. 9.7%, p = 0.025), clinically driven TLR (14.8 vs. 6%, p = 0.009), and TVMI (10.2 vs. 4.2%, p = 0.048) were notably higher in the NC group than in the DKC group. The midterm MACE rate in the overall population notably differed between the NC group and the DKC group (adjusted HR (IPW): 2.712, [95% CI: 1.407-5.228], p = 0.003).

CONCLUSION

In patients with CBLs, applying the DKC technique for bifurcation treatment had better ischemia-driven outcomes than the NC technique.

Kissing Balloon-Stent Technique for Simple Bifurcation Lesions

Background: Coronary bifurcation lesions are commonly encountered during coronary angiography. The management of bifurcation lesions remains challenging, with various bifurcation techniques being available and outcomes varying depending on the Medina classification and operator experience. Methods: We present a short case series and the outcomes of a new bifurcation technique for the management of simple Medina '0,0,1' and '0,0,1' bifurcation lesions using the kissing balloon-stent technique (kissing BS). Results: We retrospectively identified 8 patients who underwent bifurcation stenting using the kissing Balloon-Stent technique, along with their clinical and angiographic follow-up outcomes. We also describe the benefits and limitations of the technique, delineate the potential mechanisms of target lesion failure, and outline appropriate patient selection. Conclusions: Kissing Balloon-Stent technique is a simple single stent technique that is safe and feasible in select patients with Medina '0,0,1' and '0,0,1' bifurcation lesions.

Long-term outcomes following double kissing crush or mini-culotte stenting for complex coronary bifurcation lesions: the EVOLUTE-CRUSH IV study

BACKGROUND

This study aimed to evaluate the long-term outcomes of double kissing crush stenting (DKC) and mini-culotte technique (MCT) in patients with complex bifurcation lesions.

METHODS

This retrospective study enrolled 236 patients who underwent percutaneous coronary intervention (PCI) for complex coronary bifurcation disease between January 2014 and November 2022. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, myocardial infarction (MI), or clinically driven target lesion revascularization (TLR). The secondary endpoint was major cardiovascular and cerebral events (MACCE) including all-cause death, MI, TLR, stroke, or stent thrombosis. The regression models were adjusted by applying the inverse probability weighted (IPW) approach to reduce treatment selection bias.

RESULTS

The initial management strategy was DKC in 154 (65.3%) patients and MCT in 82 (34.7%) patients (male: 194 [82.2%], mean age: 60.85 ± 10.86 years). The SYNTAX scores were similar in both groups. The rates of long-term TLF and MACCE rates were 17.4% and 20%, respectively. The rate of TLF (26.8% vs. 12.3%, p = 0.005) was higher in patients treated with MCT than those treated with the DKC technique, mainly driven by more frequent TLR (15.9% vs. 7.1%, p = 0.035). The long-term TLF and MACCE rates were notably lower in the DKC group compared to the others: adjusted hazard ratio (HR; IPW): 0.407, p = 0.009 for TLF, and adjusted HR(IPW): 0.391 [95% CI: 0.209-0.730], p = 0.003 for MACCE.

CONCLUSION

At long-term follow-up, the rates of TLF and MACCE were 17.4% and 20%, respectively. However, long-term TLF was significantly higher in patients treated with MCT than those treated with the DKC technique, primarily due to a more frequent occurrence of clinically driven TLR.

Residence time in complex left main bifurcation disease after stenting

BACKGROUND

Data regarding the mean resident time (RT) after left main (LM) bifurcation stenting are scant. In the present study we performed a patient-specific computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in LM patients treated with single-or double stenting techniques.

METHODS

Patients were identified after reviewing the local Optical Coherence Tomography (OCT) scans database. Overall, 27 patients (mean age 65.5 ± 12.4, 21 males) [10 patients treated with provisional cross-over stenting, 7 with the double kissing crush (DK crush) and 10 with the nano-inverted T (NIT) technique, respectively] with isolated and significant LM bifurcation disease were analyzed.

RESULTS

After LM bifurcation stenting, the NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and provisional cross-over stenting. Moreover, the mean RT resulted lower after NIT compared to provisional or DK crush. During the diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional.

CONCLUSION

The present OCT-derived CFD analysis revealed that, in patients with complex bifurcation LM disease, the provisional approach resulted in lower WSS values, while double stenting techniques, especially the NIT technique, resulted in a marked reduction of average RT compared to the provisional approach.

CONDENSED ABSTRACT

In the present study we performed a patient-specific Optical coherence tomography (OCT)-based computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in 27 patients treated with provisional cross-over stenting, DK crush and Nano-inverted-T (NIT) stenting. The NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and Provisional. The mean RT resulted lower in NIT compared to Provisional or DK crush. During the entire diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the entire LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional.

Comparison of long-term outcomes of double kissing crush versus T and minimal protrusion techniques in complex bifurcation lesions: The EVOLUTE-CRUSH II registry

BACKGROUND

Double kissing (DK)-crush and T-stenting and small protrusion (TAP) techniques are gaining popularity, but the comparison for both techniques is still lacking. This study sought to retrospectively evaluate the long-term outcomes of DK-crush and TAP techniques in patients with complex bifurcation lesions.

METHODS

A total of 255 (male: 205 [80.3%], mean age: 59.56 ± 10.13 years) patients who underwent coronary bifurcation intervention at a single-center between January 2014 and May 2021 were included. Angiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization (TLR). The regression models were adjusted applying by the inverse probability weighted (IPW) approach to reduce treatment selection bias.

RESULTS

The initial management strategy was DK-crush in 152 (59.6%) patients and TAP in 103 (40.4%) cases. The SYNTAX scores (24.58 ± 7.4 vs. 24.26 ± 6.39, p = 0.846) were similar in both groups. The number of balloon (6.32 ± 1.82 vs. 3.92 ± 1.19, p < 0.001) usage was significantly higher in the DK-crush group than in the TAP group. The rates of TLF (11.8 vs. 22.3%, p = 0.025) and clinically driven TLR (6.6 vs. 15.5%, p = 0.020) were significantly lower in the DK-crush group compared to the TAP group. The long-term TLF was significantly higher in the TAP group compared to the DK-crush group (unadjusted HR: 1.974, [95% CI: 1.044-3.732], p = 0.035 and adjusted HR [IPW]: 2.498 [95% CI: 1.232-5.061], p = 0.011).

CONCLUSION

The present study showed that the DK-crush technique of bifurcation treatment was associated with lower long-term TLF and TLR rates compared to the TAP technique.

Variability in research culture across busy catheterisation labs in the Asia-Pacific region

Background

Information related to research culture in the busy catheterisation (cath) labs across the Asia-Pacific (APAC) region is sparse.

Aims

The aims of this study were to examine the variability in research culture in busy cath labs in the APAC region and to propose a roadmap for hospitals to develop in-house research capabilities in conjunction with industry and academia.

Methods

Data related to research practices in the APAC region were collected from busy cath labs (at least 250 angioplasty/year) and analysed. Results were shared with research experts to understand the challenges in institutional research and create a roadmap for hospitals to develop research capabilities.

Results

A total of 220 respondents from 62 cath labs (88.6%) across 13 APAC countries participated in the survey. A wide variation was noted in research culture across APAC countries. Well-established infrastructure was reported in Australia, New Zealand, South Korea, Singapore, and Japan. Large multicentre trials were common in South Korea, while routine follow-ups were common in Japan. Linking medical records across hospitals/states was considered challenging. Research exposure and training were limited in the APAC region. The experts suggested a roadmap, including creating a conducive regulatory environment, forming synergistic goals, training programs for the professionals involved in research, and leveraging best practices, for improving the research culture in APAC.

Conclusions

Clinical research in cardiology has grown significantly in the APAC region, with a huge research potential in China and India. Implementing measures to improve research training and involvement of the industry will boost the research culture in the APAC region.

Proximal optimization technique and percutaneous coronary intervention for left main disease: POTENTIAL-LM

BACKGROUND

Optimal stent deployment in left main (LM) bifurcation is paramount, and incomplete stent apposition may cause major adverse cardiac events (MACE). Bench studies show that the proximal optimization technique (POT) provides the best stent apposition.

AIMS

We aimed to investigate the impact of POT on clinical outcomes in patients treated for unprotected LM (ULM) disease at our institution.

METHODS

We identified 162 patients who underwent percutaneous coronary intervention (PCI) for ULM coronary disease in the Cardio-FR database. Out of these, 99 (61%) had undergone POT, while 63 patients were treated without POT. The primary outcome was the bifurcation-oriented composite endpoint (BOCE) of cardiac death, target-bifurcation myocardial infarction and target-bifurcation revascularization at maximal follow-up.

RESULTS

Mean age was 76 years, and 69% presented with acute coronary syndrome. Mean follow-up was 2.25 years (822 days). The BOCE occurred in 43 (27%) of which 20 (20%) in the POT group and 23 (37%) in the no-POT group (p = 0.009). Cardiac death occurred in 15 (15%) patients in the POT- and 17 (27%) in no-POT group (p = 0.26). Target bifurcation revascularization occurred in 4 (4%) patients in the POT- and 6 (10%) patients in the no-POT group (p = 0.19). POT In the multivariate analysis, POT was the strongest parameter and was associated with BOCE, cardiac death, occurrence of any revascularization and all-cause mortality.

CONCLUSION

The POT improves clinical outcomes. These findings strongly support the systematic use of POT in patients undergoing ULM-PCI.

Optimal Minimal Stent Area and Impact of Stent Underexpansion in Left Main Up-Front 2-Stent Strategy

BACKGROUND

We previously reported the use of minimal stent area to predict angiographic in-stent restenosis after drug-eluting stent implantation for unprotected left main (LM) disease. We aimed to evaluate the optimal minimal stent area criteria for up-front LM 2-stenting based on long-term clinical outcomes.

METHODS

We identified 292 consecutive patients with LM bifurcation stenosis who were treated using the crush technique. The final minimal stent area was measured in the ostial left anterior descending artery (LAD), ostial left circumflex artery (LCX), and distal LM. The primary outcome was 5-year major adverse cardiac events, including all-cause death, myocardial infarction, and target lesion revascularization.

RESULTS

The minimal stent area cutoff values that best predicted the 5-year major adverse cardiac events were 11.8 mm2 for distal LM (area under the curve, 0.57; P=0.15), 8.3 mm2 for LAD ostium (area under the curve, 0.62; P=0.02), and 5.7 mm2 for LCX ostium (area under the curve, 0.64; P=0.01). Using these criteria, the risk of 5-year major adverse cardiac events was significantly associated with stent underexpansion in the LAD ostium (hazard ratio, 3.14; [95% CI, 1.23-8.06]; P=0.02) and LCX ostium (hazard ratio, 2.60 [95% CI, 1.11-6.07]; P=0.03) but not in the distal LM (hazard ratio, 0.81 [95% CI, 0.34-1.91]; P=0.63). Patients with stent underexpansion in both ostial LAD and LCX had a significantly higher rate of 5-year major adverse cardiac events than those with no or 1 underexpanded stent of either ostium (P<0.01).

CONCLUSIONS

Stent underexpansion in the LAD and LCX ostium was significantly associated with long-term outcomes in patients who underwent up-front 2-stenting for LM bifurcation stenosis.

Optical Coherence Tomography Predictors of SIde Branch REstenosis after unprotected Left Main bifurcation angioplasty using double kissing crush technique (OP-SIBRE LM Study)

BACKGROUND

Among the two stent strategies, contemporary evidence favors double kissing crush technique (DKC) for complex unprotected distal left main bifurcation (UdLMB) lesions. However one of the major challenges to these lesions is side branch (SB) restenosis.

AIMS

Our aim was to identify optical coherence tomographic (OCT) characteristics that may predict SB restenosis (SBR) after UdLMB angioplasty using DKC technique.

METHODS

This was a single-center, retrospective study that included 60 patients with complex UdLMB disease, who underwent OCT-guided angioplasty using DKC technique. Angiographic follow-up was performed in all patients at 1 year to identify patients with SBR. Patients with SBR group were compared with patients without SBR (NSBR group) for OCT parameters during index procedure.

RESULTS

Twelve (20%) patients developed SBR at 1-year follow-up. The SBR group had longer SB lesion (18.8 ± 3.2 vs. 15.3 ± 3.7 mm, p = 0.004) and neo-metallic carinal length (2.1 vs. 0.1 mm, p < 0.001) when compared to the NSBR group. Longer neo-metallic carinal length was associated with the absence of the dumbbell sign, presence of hanging stent struts across the SB ostium on OCT of final MB pullback. On multivariate regression analysis, SB distal reference diameter (DRD) and SB stent expansion were identified as independent predictors of SBR with SB-DRD of ≤2.8 mm (area under curve-0.73, sensitivity-83.3%, and specificity-62.5%) and SB stent expansion of ≤89% (area under curve-0.88, sensitivity-83.3%, and specificity- 81.2%) as the best cut off values to predict SBR.

CONCLUSIONS

SB DRD and SB stent expansion are the OCT predictors of future SBR after UdLMB angioplasty using DKC technique.

Bifurcation PCI with a hybrid strategy with drug- eluting balloons versus a stepwise provisional two- stent strategy: Rationale and design of the hybrid DEB study

The optimal treatment strategy for coronary bifurcation lesions by percutaneous coronary intervention (PCI) is complex and remains a subject of debate. Current guidelines advise a stepwise provisional approach with optional two-stent strategy. However, a two-stent strategy, both upfront and stepwise provisional, is technically demanding. Therefore, there is increasing interest in the use of drug-eluting balloons (DEB) in bifurcation lesions, mainly after a provisional approach with unsatisfactory result of the side branch. Some small pilot studies already showed that the use of DEB in bifurcation lesions is safe and feasible. However, a randomized comparison of this hybrid DEB strategy with a two-stent strategy is currently lacking.

TRIAL DESIGN

The Hybrid DEB study is a prospective, multicenter, randomized controlled trial investigating noninferiority of a hybrid DEB approach, using a combination of a drug-eluting stent (DES) in the main vessel and DEB in the side branch, compared to stepwise provisional two-stent strategy in patients with true bifurcation lesions. A total of 500 patients with de novo true coronary bifurcation lesions, treated with a stepwise provisional approach and an unsatisfactory result of the side branch after main vessel stenting (≥ 70% stenosis and/or < thrombolysis in myocardial infarction III flow), will be randomized in a 1:1 ratio to receive either treatment with a DEB or with a DES in the side branch. The primary endpoint is a composite endpoint of the occurrence of all-cause death, periprocedural or spontaneous myocardial infarction and/or target vessel revascularization at the anticipated median 2-year follow-up.

CONCLUSION

The Hybrid DEB study will compare in a multicenter, randomized fashion a hybrid DEB approach with a stepwise provisional two-stent strategy in patients with true bifurcation lesions.

TRIAL REGISTRATION

ClinicalTrials.gov no. NCT05731687.

A novel hybrid strategy of drug coated balloon and stent for coronary bifurcation lesions

Background. Provisional side branch (SB) stenting strategy is the default approach for the majority of bifurcation lesions, but outcomes of SB is suboptimal. Though drug coated balloon (DCB) improving SB outcomes attracts an increasing attention, sequence of DCB hasn't yet been determined. We presented a novel hybrid strategy of DCB and stent for bifurcation lesions. Methods. With lesion preparation, DCB was persistently inflated in SB kissing with main branch (MB) stent deployment and balloon post-dilation of the bifurcation core. Proximal optimization technique was performed strictly not exceeding the bifurcation. Procedural and clinical adverse events were evaluated. Canadian Cardiovascular Society (CCS) angina classification was assessed at baseline and clinical follow-up. Results. Fourteen patients undergoing the hybrid technique from August 2020 to July 2021 were enrolled. The technique was successfully performed in all patients without rewiring or SB compromise. Minimal lumen diameter of SB increased from 0.60 ± 0.40 mm to 2.1 ± 0.2 mm while the percent stenosis decreased from 72.4 ± 17.9% to 19.6 ± 4.7%. In addition, intravascular ultrasound indicated comparable stent symmetry index and incomplete stent apposition between proximal and distal segments of stent. No further intervention was performed, and mean fractional flow reserve of SB (n = 12) was 0.88 ± 0.05. No major adverse cardiac events was noted in hospital and 12-month follow up. The mean CCS angina score was reduced by 84% (2.2 vs 0.4, p < .001). Conclusion. The hybrid strategy facilitates treatment of DCB and stent for bifurcation lesions, which appears to be feasible and acceptable in a short-term follow-up.

Cardiovascular Outcomes After Mini-Crush or Double Kissing Crush Stenting Techniques for Complex Bifurcation Lesions: The EVOLUTE-CRUSH Registry

Comparison of clinical outcomes of double kissing crush (DKC) and mini-crush (MC) techniques in patients with complex coronary bifurcation lesions is lacking. This study sought to determine the clinical results of DKC and MC stenting techniques in mid-term follow-up. This retrospective study included a total of 269 consecutive patients with complex bifurcation lesions who underwent percutaneous coronary intervention; 132 (49%) of them were treated with MC technique, whereas 137 (51%) treated with DKC technique. The primary end point was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. This is the first study to compare the cardiovascular outcomes of DKC and MC stenting techniques in patients with complex bifurcation lesions. The SYNTAX scores were similar in both groups (23 [20 to 30] vs 23 [19 to 28], p = 0.631)]. The number of balloons (6.31 ± 1.80 vs 4.42 ± 0.87, p <0.001) and guidewires (3.55 ± 0.83 vs 2.86 ± 0.74, p <0.001) used, fluoroscopy time (21.55 ± 7.05 vs 16.66 ± 4.19 minutes, p <0.001), and procedure time (80.42 ± 27.95 vs 69.61 ± 18.97 minutes, p <0.001) were significantly higher in the DKC group. The rate of composite TLF was similar in complex bifurcation patients treated with MC than those treated with the DKC technique (14% vs 12%, p = 0.453). Moreover, both groups had similar rates in terms of cardiac death or all-cause death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis. In conclusion, the present study showed that both techniques of bifurcation treatment met high angiographic success with low complication and similar TLF rates.

Clinical and procedural outcomes of percutaneous coronary intervention for de novo lesions involving the ostial left circumflex coronary artery

BACKGROUND

Percutaneous treatment for ostial left circumflex artery (LCx) lesions is known to be associated with suboptimal results.

AIMS

The present study aims to assess the procedural and long-term clinical outcomes of percutaneous coronary intervention (PCI) for de novo ostial LCx lesions overall and according to the coronary revascularization strategy.

METHODS

Consecutive patients undergoing PCI with second generation drug eluting stents or drug coated balloons for de novo ostial LCx lesions in three high-volume Italian centers between 2012 and 2021 were retrospectively evaluated. The primary endpoint was target-vessel revascularization (TVR) at 2 years. Secondary endpoints included major adverse cardiovascular and cerebrovascular events (MACCE), target lesion revascularization, myocardial infarction, stroke, all-cause death, and repeat revascularization.

RESULTS

A total of 366 patients were included in the analysis with a median follow-up of 901 (IQR: 450-1728) days. 79.5% of the patients were male, 33.6% were diabetic, 49.7% had a previous PCI, and 23.1% a prior surgical revascularization. Very ostial LCx stenting was performed in 34.1%, crossover from left main to LCx in 17.3%, and a two-stent strategy in 48.6% of cases, respectively. In the overall population, the incidence of TVR at 2 years was 19.0% while MACCE rate was 25.7%. No major differences in clinical outcomes were found according to the stenting strategy. Use of intracoronary imaging was associated with fewer MACCE (HR: 0.47, 95% CI: 0.25-1.13, p = 0.01), while the diameter of the stent implanted in the ostial LCx was associated with less TVR (HR: 0.43, 95% CI: 0.25-0.75, p = 0.002).

CONCLUSIONS

Percutaneous revascularization of the ostial LCx is associated with a high rate of TVR, regardless of the stenting strategy. Intracoronary imaging and proper stent sizing may reduce the failure rates.

Clinical Outcomes Following Bifurcation Techniques for Percutaneous Coronary Intervention

Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis [...].

Comparison of Outcomes Between 1- and 2-Stent Techniques for Medina Classification 0.0.1 Coronary Bifurcation Lesions

BACKGROUND

Although Medina 0.0.1 bifurcation lesions are often treated by percutaneous coronary intervention (PCI) in real-world practice, the optimal revascularization strategy for this lesion is uncertain.

OBJECTIVES

The current study aimed to compare the clinical outcomes between 1- and 2-stent strategies in patients treated with PCI for Medina 0.0.1 bifurcation lesions.

METHODS

The extended BIFURCAT (Combined Insights From the Unified RAIN [Very Thin Stents for Patients with Left Main or Bifurcation in Real Life] and COBIS [Coronary Bifurcation Stenting] Bifurcation Registries) registry was obtained by patient-level merging the dedicated bifurcation COBIS II, III, and RAIN registries. Among 8,434 patients with bifurcation lesions undergoing PCI, 345 (4.1%) with Medina 0.0.1 lesions were selected for the current analysis. The primary endpoint was major adverse cardiac event (MACE, a composite of all-cause death, myocardial infarction, target vessel revascularization, and stent thrombosis) at 800 days.

RESULTS

In the total population, 209 patients (60.6%) received PCI with a 1-stent strategy and the remaining 136 patients (39.4%) with a 2-stent strategy. There was a tendency for higher use of a 1-stent strategy over time (36.0%, 47.4%, and 90.4% in 2003-2009, 2010-2014, and 2015-2017, respectively; P for trend < 0.001). For the treatment of Medina 0.0.1 lesions, there was no significant difference in the risk of MACE between 1- and 2-stent strategies (1 stent vs 2 stent, 14.3% vs 13.9%; HR: 1.034; 95% CI: 0.541-1.977; P = 0.92). The risk of MACE was also not significantly different when stratifying into 3 groups (1-stent crossover only, 1-stent with strut opening, and 2-stent strategy).

CONCLUSIONS

In patients with a Medina 0.0.1 type bifurcation lesion, PCI with a 1-stent strategy showed comparable outcomes to that of a 2-stent strategy. (Coronary Bifurcation Stenting II [COBIS II]; NCT01642992; Coronary Bifurcation Stenting III [COBIS III]; NCT03068494; Very Thin Stents for Patients with Left Main or Bifurcation in Real Life [RAIN]; NCT03544294).

Clinical prognostic value of a novel quantitative flow ratio from a single projection in patients with coronary bifurcation lesions treated with the provisional approach

Background

A novel quantitative flow ratio (μQFR) for bifurcated coronary vessels, derived from a single projection, has been recently reported. Provisional stenting is effective for most bifurcation lesions. However, the clinical value of the side branch (SB) μQFR in patients with coronary bifurcation lesions undergoing provisional stenting remains unclear.

Aims

This study aims to determine the clinical predictive value of the SB μQFR after provisional stenting in patients with coronary bifurcation lesions.

Methods

Between June 2015 and May 2018, 288 patients with true coronary bifurcation lesions who underwent a provisional approach without SB treatment (including predilation, kissing balloon inflation or stenting) were classified by an SB μQFR <0.8 (n=65) and ≥0.8 (n=223) groups. The primary endpoint was the three-year composite of target vessel failure (TVF), including cardiac death, target vessel myocardial infarction (TVMI), and revascularisation (TVR).

Results

Three years after the procedures, there were 43 (14.9%) TVFs, with 19 (29.2%) in the SB μQFR <0.8 and 24 (10.8%) in the SB μQFR ≥0.8 groups (adjusted hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.39-5.54; p=0.003), mainly driven by increased TVMI (16.9% vs 5.4%, adjusted HR 3.29, 95% CI: 1.15-6.09; p=0.030) and TVR (15.4% vs 2.2%, adjusted HR 6.39, 95% CI: 2.04-13.48; p=0.007). Baseline diameter stenosis at the ostial SB and SB lesion length were the two predictors of an SB μQFR <0.8 immediately after stenting the main vessel, whereas previous percutaneous coronary intervention and an SB μQFR <0.8 were the two independent factors of 3-year TVF.

Conclusions

An SB μQFR <0.8 immediately after the provisional approach is strongly associated with clinical events. Further randomised studies with large patient populations are warranted.

Bifurcation left main stenting with or without intracoronary imaging: Outcomes from the EBC MAIN trial

BACKGROUND

The impact of intracoronary imaging on outcomes, after provisional versus dual-stenting for bifurcation left main (LM) lesions, is unknown.

OBJECTIVES

We investigated the effect of intracoronary imaging in the EBC MAIN trial (European Bifurcation Club LM Coronary Stent study).

METHODS

Four hundred and sixty-seven patients were randomized to dual-stenting or a stepwise provisional strategy. Four hundred and fifty-five patients were included. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was undertaken at the operator's discretion. The primary endpoint was death, myocardial infarction or target vessel revascularization at 1-year.

RESULTS

Intracoronary imaging was undertaken in 179 patients (39%; IVUS = 151, OCT = 28). As a result of IVUS findings, operators reintervened in 42 procedures. The primary outcome did not differ with intracoronary imaging versus angiographic-guidance (17% vs. 16%; odds ratio [OR]: 0.92 (95% confidence interval [CI]: 0.51-1.63) p = 0.767), nor for reintervention based on IVUS versus none (14% vs. 16%; OR: 0.88 [95% CI: 0.32-2.43] p = 0.803), adjusted for syntax score, lesion calcification and ischemic symptoms. With angiographic-guidance, primary outcome events were more frequent with dual versus provisional stenting (21% vs. 10%; adjusted OR: 2.11 [95% CI: 1.04-4.30] p = 0.039). With intracoronary imaging, there were numerically fewer primary outcome events with dual versus provisional stenting (13% vs. 21%; adjusted OR: 0.56 [95% CI: 0.22-1.46] p = 0.220).

CONCLUSIONS

In EBC MAIN, the primary outcome did not differ with intracoronary imaging versus none. However, in patients with angiographic-guidance, outcomes were worse with a dual-stent than provisional strategy When intracoronary imaging was used, there was a trend toward better outcomes with the dual-stent than provisional strategy.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Importance of optimal rewiring guided by 3-dimensional optical frequency domain imaging during double-kissing culotte stenting demonstrated through a novel bench model

The usefulness of optical frequency domain imaging (OFDI) guidance on two-stenting at left main bifurcation has not been evaluated. Here, we used a novel bench model to investigate whether pre-defined optimal rewiring with OFDI-guidance decreases acute incomplete stent apposition (ISA) at the left main bifurcation segment. A novel bench simulation system was developed to simulate the foreshortening and overlapping of daughter vessels as well as left main bifurcation motion under fluoroscopy. Double-kissing (DK) culotte stenting was performed using the novel bench model under fluoroscopy with or without OFDI-guidance. In the OFDI-guidance group, if the guidewire did not pass through the pre-defined optimal cell according to the 3-dimensional OFDI, additional attempts of rewiring into the jailed side branch were performed. The success rate of optimal jailed side branch rewiring after implantation of the first and second stent under OFDI-guidance was significantly higher than that under only angio-guidance. After completion of the DK-culotte stenting, the incidence and volume of ISA at the bifurcation segment in the OFDI-guidance group was significantly lower than that in the angio-guidance group. Online 3-dimensional OFDI-guided DK-culotte stenting according to a pre-defined optimal rewiring point might be superior to only angio-guided rewiring for reducing ISA at the bifurcation.

T and Small Protrusion (TAP) Technique in Bifurcations: Coronary Artery Disease in Acute Myocardial Infarction Patients after COVID-19 Pneumonia

Ischemic coronary artery disease in all its forms remains the main cause of death worldwide. Coronary artery bifurcation lesions are a challenge because of their complexity and possible complications. The goal of treating bifurcation lesions is the optimal revascularization of the main vessel without compromising the side branch. Although the study of bifurcation stenting aims to keep the side branch viable, the outcomes regarding major acute cardiovascular events and survivability are related to the optimal treatment of the main vessel. There are many trials that have tried to evaluate the best technique to use with respect to bifurcation lesions, and early studies support provisional stenting as the election treatment. More recent trials highlighted the superior outcomes of the double kissing crush technique used on unprotected distal left main bifurcation lesions. In patients with acute myocardial infarction, two-stent techniques were avoided because of the prolonged procedural time in unstable patients, with high risks of complications. We present the case of a 53-year-old woman with multiple cardiovascular risk factors (dyslipidemia, hypertension, active cancer, post-COVID-19 state) and acute antero-lateral myocardial infarction who underwent primary coronary intervention with the use of the TAP technique for stenting the bifurcation culprit coronary lesion (left anterior descendent artery and first diagonal artery).

STICH3C: Rationale and Study Protocol

BACKGROUND

Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here.

METHODS

The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG.

RESULTS

The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years.

CONCLUSIONS

STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease.

REGISTRATION

URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.

Comparing the clinical outcomes of single vs. systematic dual stenting strategies for unprotected left main bifurcation lesion: a systematic review and meta-analysis

INTRODUCTION

The optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. This meta-analysis compared the medium and long-term follow-up clinical outcomes of single vs. systematic dual stenting strategies of LM bifurcation lesions.

METHODS

We systematically identified studies published within 5 years comparing single vs. systematic double stenting strategies for LM bifurcation lesions. The primary endpoint was medium-term (1 year) and long-term (at least 3 years) all-cause death. Secondary outcomes included major adverse cardiovascular events (MACEs), target lesion revascularization (TLR), overall occurrence of stent thrombosis (ST), cardiovascular (CV) mortality, and myocardial infarction (MI).

RESULTS

Two randomized controlled trials and nine observational studies with 7,318 patients were included in this meta-analysis. In terms of the medium-term follow-up clinical outcomes, our pooled analysis showed that use of the systematic dual stenting strategy was associated with a lower ST risk (odds ratio [OR] = 0.43, 95% confidence interval [CI]: 0.20-0.89, P = 0.02) and cardiac death risk (OR = 0.43, 95% CI: 0.21-0.89, P = 0.02) compared to the single stenting strategy; there was no significant difference between the two strategies regarding rates of all-cause death, MACE, TLR, and MI. Patients with long-term follow-up showed comparable observed clinical outcomes between the two strategies. Most importantly, for patients with true LM bifurcation, the risk of all-cause death, ST, and CV mortality following the systematic dual stenting strategy was significantly lower than the single stenting strategy.

CONCLUSIONS

For patients with LM bifurcation lesions, both the systematic dual stenting strategy and single stenting strategy demonstrated comparable results in terms of all-cause mortality during medium-term and long-term follow-up. However, the systematic dual stenting strategy showed a tendency towards lower incidence of ST and CV mortality compared to the single stenting strategy during medium-term follow-up. Consequently, the systematic dual stenting strategy yielded superior clinical outcomes for patients with LM bifurcation lesions.

Physiology-guided PCI versus CABG for left main coronary artery disease: insights from the DEFINE-LM registry

There have been no studies comparing clinical outcomes of physiology-guided revascularization in patients with unprotected left main coronary disease (ULMD) between percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG). The aim of this study was to assess the long-term clinical outcomes between PCI and CABG of patients with physiologically significant ULMD. From an international multicenter registry of ULMD patients interrogated with instantaneous wave-free ratio (iFR), we analyzed data from 151 patients (85 PCI vs. 66 CABG) who underwent revascularization according to the cutoff value of iFR ≤ 0.89. Propensity score matching was employed to adjust for baseline clinical characteristics. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were the individual components of the primary endpoint. Mean age was 66.6 (± 9.2) years, 79.2% male. Mean SYNTAX score was 22.6 (± 8.4) and median iFR was 0.83 (IQR 0.74-0.87). After performing propensity score matching analysis, 48 patients treated with CABG were matched to those who underwent PCI. At a median follow-up period of 2.8 years, the primary endpoint occurred in 8.3% in PCI group and 20.8% in CABG group, respectively (HR 3.80; 95% CI 1.04-13.9; p = 0.043). There was no difference in each component of the primary event (p > 0.05 for all). Within the present study, iFR-guided PCI was associated with lower cardiovascular events rate in patients with ULMD and intermediate SYNTAX score, as compared to CABG. State-of-the-art PCI vs. CABG for ULMD. Study design and primary endpoint in patients with physiologically significant ULMD. MACE was defined as the composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. The blue line denotes the PCI arm, and the red line denotes the CABG arm. PCI was associated with significantly lower risk of MACE than CABG. CABG: coronary artery bypass grafting; iFR: instantaneous wave-free ratio; MACE: major adverse cardiovascular events; PCI: percutaneous coronary intervention; ULMD: unprotected left main coronary artery disease.

Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review

The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

Long-term clinical outcomes of percutaneous coronary intervention for ostial left main coronary artery disease

BACKGROUND

There are limited data regarding the long-term prognosis of percutaneous coronary intervention treatment for left main (LM) ostial stenosis.

AIMS

The present study sought to investigate the long-term clinical outcomes and risk factors for adverse events in LM ostial lesions following drug-eluting stent implantation (DES) in a large cohort of an LM registry database.

METHODS

Patients presenting with LM coronary disease from January 2004 to December 2016 at Fuwai Hospital were included. The primary endpoint was target vessel failure (TVF), a composite endpoint of cardiac death, target vessel myocardial infarction and target vessel revascularisation. Cox proportional hazards models were constructed to identify independent predictors.

RESULTS

Among 4,625 LM patients, 627 (13.6%) patients were identified with LM ostial lesions. There were more female patients in the ostial group (31.3%), compared with the shaft (18.1%) and bifurcation groups (19.9%) (p<0.0001). Among patients with DES implantation, 3-year TVF occurred in 44 patients (7.5%) in the ostial group, which is comparable with the other two groups. Myocardial infarction (MI) was significantly lower in the ostial group (2.0%) compared with the bifurcation group (4.2%) (p=0.02), especially for MI events originating in the LM vessel (p=0.02). For patients with ostial LM disease who received percutaneous coronary intervention (PCI) treatment, procedural complications were an independent risk factor for long-term cardiac death or MI, while a more recent PCI proved to be a protective factor.

CONCLUSIONS

PCI treatment for ostial LM lesions achieved favourable long-term outcomes, with a similar MI risk compared with the mid-shaft group but a significantly lower risk of MI compared with the distal group.

Unprotected Left Main Bifurcation Stenting in Acute Coronary Syndromes: Two-Stent Technique versus One-Stent Technique

AIMS

There is little evidence guiding the choice between a one-stent and a two-stent approach in unprotected distal left main coronary artery disease (UDLMCAD) presenting as acute coronary syndrome (ACS). We aim to compare these two techniques in an unselected ACS group.

METHODS AND RESULTS

We conducted a single center retrospective observational study, that included all patients with UDLMCAD and ACS undergoing PCI between 2014 and 2018. Group A underwent PCI with a one-stent technique (n = 41, 58.6%), Group B with a two-stent technique (n = 29, 41.4%). A total of 70 patients were included, with a median age of 63 years, including n = 12 (17.1%) with cardiogenic shock. There were no differences between Group A and B in terms of patient characteristics, including SYNTAX score (median 23). The 30-day mortality was 15.7% overall, and was lower in Group B (3.5% vs. 24.4%, p = 0.02). Mortality rate at 4 years was significantly lower in Group B (21.4% vs. 44%), also when adjusted in a multivariable regression model (HR 0.26, p = 0.01).

CONCLUSIONS

In our study, patients with UDLMCAD and ACS undergoing PCI using a two-stent technique had lower early and midterm mortality compared to one-stent approach, even after adjusting for patient-related or angiographic factors.

Provisional Strategy for Left Main Stem Bifurcation Disease: A State-of-the-Art Review of Technique and Outcomes

Left main coronary artery (LMA) disease jeopardizes a large area of myocardium and increases the risk of major adverse cardiovascular events. LMCA disease is found in 5% to 7% of all diagnostic coronary angiographies, and more than 80% of the patients enrolled in recent large randomized controlled left main trials had distal left main bifurcation or trifurcation disease. Emerging clinical evidence from prospective all-comer registries and randomized trials has provided a solid basis for percutaneous coronary intervention as a treatment option in selected patients with unprotected LMCA disease; however, to date, no uniform recommendations as to optimal stenting strategy for LMCA bifurcation lesions exist. This review provides an overview of provisional stenting technique and escalation to 2-stent strategies in LMCA bifurcation lesions. Data from randomized controlled trials and registries are reviewed. Technical characteristics of optimal provisional LMCA stenting technique and angiographic and intravascular determinants of escalation are also summarized.

Management of failed stenting of the unprotected left main coronary artery

Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.

Long-term prognostic value of Murray law-based quantitative flow ratio in jailed left circumflex coronary artery after left main crossover stenting

We aimed to evaluate the impact of new Murray law-based QFR of jailed left circumflex coronary artery (LCx) on long-term clinical outcomes after left main coronary artery (LM) simple crossover stenting. 164 patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and had appropriate angiographic view of LCx for QFR computation were enrolled. The primary clinical outcome was the 5-year target lesion failure (TLF), defined as a composite of cardiac death, a target vessel myocardial infarction or target lesion repeat revascularization. The mean QFR of the LCx after LM stent implantation was 0.88 ± 0.09, and 29 patients (17.7%) had a low QFR (< 0.80), which was significantly associated with a higher 5-year rate of TLF when compared with the high QFR group (27.6% vs. 6.7%; HR: 4.235; 95% CI 1.21-14.95; p = 0.0015). The 5-year LCx ostium-related TLR rate in the low QFR group was also higher (17.2% vs. 3.0% in the high QFR group; HR: 6.07, 95% CI 1.63-22.59, p = 0.002). In a multivariate Cox regression analysis, a low QFR in the LCx after LM stenting was an independent predictor of the 5-year TLF rate (HR: 3.21, 95% CI 1.21-8.53; p = 0.019). ROC analysis showed that QFR a negative predictive value (NPV) of 89.6% ([AUC] 0.73, 95% CI 0.58-0.88, p < 0.05), the cutoff point is 0.85. The patients with a low QFR (< 0.80) in jailed LCX after LM simple crossover stenting had worse 5-year outcomes than those with a high QFR. Conversely, a QFR ≥ 0.85 of jailed LCx could serve as a good predictor of low risk of adverse outcome in LCx ostium. The QFR computation of the jailed LCx may be helpful to determine whether an additional procedure is required for the jailed side branch.

DEFINITION criteria for left main bifurcation stenting - from clinical need to a formula

Percutaneous coronary intervention using drug-eluting stents for coronary bifurcation lesions is associated with higher rates of in-stent restenosis, myocardial infarction, and revascularisation as compared with non-coronary bifurcation lesions. The increased percentage of suboptimal results after stenting bifurcation lesions is largely, if not always, due to the extreme complexity of the anatomy. Obviously, one weapon (stenting technique) does not suit all enemies (bifurcation lesions with different anatomies), and it underscores the importance of establishing a stratification system.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease

Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.

A large, prospective, multicentre study of left main PCI using a latest-generation zotarolimus-eluting stent: the ROLEX study

BACKGROUND

Data on left main (LM) percutaneous coronary interventions (PCI) have mostly been obtained in studies using drug-eluting stent (DES) platforms without dedicated large-vessel devices and with limited expansion capability.

AIMS

Our study aimed to investigate the safety and efficacy of LM PCI with the latest-generation Resolute Onyx DES.

METHODS

ROLEX (Revascularization Of LEft main with resolute onyX) is a prospective, multicentre study (ClinicalTrials.gov: NCT03316833) enrolling patients with unprotected LM coronary artery disease and a SYNTAX score <33 undergoing PCI with the Resolute Onyx zotarolimus-eluting coronary stent, that includes dedicated extra-large vessel platforms. The primary endpoint (EP) was target lesion failure (TLF): a composite of cardiac death, target vessel myocardial infarction (TVMI) and ischaemia-driven target lesion revascularisation (ID-TLR), at 1 year. All events were adjudicated by an independent clinical event committee. An independent core lab analysed all procedural angiograms.

RESULTS

A total of 450 patients (mean age 71.8 years, SYNTAX score 24.5±7.2, acute coronary syndrome in 53%) were enrolled in 26 centres. Of these, 77% of subjects underwent PCI with a single-stent and 23% with a 2-stent technique (8% double kissing [DK] crush, 6% culotte, 9% T/T and small protrusion [TAP] stenting). Intravascular imaging guidance was used in 45% (42% intravascular ultrasound [IVUS], 3% optical coherence tomography [OCT]). At 1 year, the primary EP incidence was 5.1% (cardiac death 2.7%, TVMI 2.7%, ID-TLR 2.0%). The definite/probable stent thrombosis rate was 1.1%. In a prespecified adjusted subanalysis, the primary EP incidence was significantly lower in patients undergoing IVUS/OCT-guided versus angio-guided PCI (2.0 vs 7.6%; hazard ratio [HR] 0.28, 95% confidence interval [CI]: 0.13-0.58; p<0.001).

CONCLUSIONS

In this large, multicentre, prospective registry, LM PCI with the Resolute Onyx DES showed good safety and efficacy at 1 year, particularly when guided by intracoronary imaging.

Twelve-month clinical outcomes of "nano-crush technique" for the treatment of bifurcation lesions using ultra-thin (60 µm) sirolimus-eluting coronary stents

BACKGROUND

Provisional stenting is preferred for bifurcation lesion; however, certain anatomical substrate does require two stents as a part of dedicated stent technique. Here, the present study evaluated outcomes of ultra-thin (60 µm) Supra family sirolimus-eluting stent (SES) (Sahajanand Medical Technologies Limited, Surat, India) for dedicated bifurcation lesions using nano-crush technique at 12 months angiographic follow-up.

METHODS

This was prospective, single-center observational study which enrolled patients with de novo bifurcation lesion and underwent angioplasty with Supra family SES using nano-crush technique at a tertiary care center in India, between March-2017 and February-2019. Primary endpoint at 12 months was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (CD-TLR). Secondary endpoints included patient-oriented composite endpoint (POCE), all-cause death, any revascularization, clinically driven target vessel revascularization, stent thrombosis, periprocedural and spontaneous MI, and device failure.

RESULTS

The study enrolled total 63 patients with a mean age of 62.5±4.9 years and had male dominance (89%). Left main (LM) bifurcation and non-LM bifurcation were observed in 21 (33%) and 42 (67%) patients, respectively. Total 50 (80%) patients had Medina class- 1,1,1. At 12 months, TLF occurred in 4 (6%) patients which included one cardiac death (1.5%), two (3.0%) TV-MI, and one CD-TLR (1.5%). POCE was observed in 6 (9.6%) patients. Stent failure was seen in 2 (3.1%) patient and one patient (1.5%) developed late stent thrombosis. Twelve months angiographic follow-up indicated intact stent patency in all other patients. On multivariate analysis, LM bifurcation, renal dysfunction, LM bifurcation with renal dysfunction, ejection fraction (<35%) and calcified lesion were found as predictors of TLF.

CONCLUSIONS

Dedicated stenting with ultra-thin Supra family SES for complex bifurcation lesion using nano-crush technique reported acceptable clinical outcomes among real-world patients and can be performed safely with ease without any procedural complications.

The "L-Sandwich" Strategy for True Coronary Bifurcation Lesions: A Randomized Clinical Trial

Background

This study explored the efficacy of the "L-sandwich" strategy, which involves the implantation of stents in the main vessel (MV) and shaft of the side branch (SB) with a drug-coated balloon (DCB) applied to the SB ostium, for coronary true bifurcation lesions.

Methods and Results

Of 99 patients with true bifurcation lesions, 38 patients underwent the "L-sandwich" strategy (group A), 32 patients underwent a two-stent strategy (group B), and 29 patients underwent a single-stent + DCB strategy (group C). Angiography outcomes (late lumen loss [LLL], minimum lumen diameter [MLD]), and clinical outcomes (major adverse cardiac events [MACEs]) were analyzed. At 6 months, the MLD of the SB ostium in groups A and B were similar (P > 0.05) and group A larger than group C (P < 0.05). The LLL of group B was the largest among the three groups (P < 0.05). The MLD of the SB shaft in groups A and B were larger than in group C (P < 0.05). The LLL of the SB shaft in group C was the lowest (P < 0.05). Two patients in group B received target vessel revascularization at the 6-month followup (P > 0.05), and patients in the other groups had no MACEs.

Conclusions

The "L-sandwich" strategy was feasible for the treatment of true coronary bifurcation lesions. It is a simpler procedure with similar acute lumen gain than the two-stent strategy, results in a larger SB lumen than the single-stent + DCB strategy, and it can also be used as a remedy for dissection following the single-stent + DCB strategy.

Drug-coated balloon in the treatment of coronary left main true bifurcation lesion: A patient-level propensity-matched analysis

Aims

An increasing body of evidence suggests that drug-coated balloon (DCB) angioplasty represents a valuable option for revascularization in selected patients with coronary bifurcation disease. However, there remains a paucity of real-world observational evidence on the efficacy of DCB in left main (LM) true bifurcation lesion. We compared clinical and angiographic outcomes of hybrid [DCB + drug-eluting stent (DES)] versus DES-only strategy (provisional stenting or two-stent strategies) in de novo LM true bifurcated lesions.

Methods

The primary endpoint was the 2-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (CD-TLR). A routine 1-year angiographic follow-up was scheduled. Propensity-score matching was utilized to assemble a cohort of patients with similar baseline characteristics.

Results

Among 1077 eligible patients, 199 who received DCB treatment and 398 who were assigned to DES therapy had similar propensity scores and were included in the analysis. TLF within 2 years occurred in 13 patients (7.56%) assigned to DCB group, and 52 patients (14.36%) assigned to DES group (odds ratio: 0.487; 95% confidence interval: 0.258–0.922; P = 0.025; Log-rank P = 0.024). Compared with the DES group, the DCB group resulted in a lower rate of CD-TLR (2.91% vs. 9.42%; P = 0.007). Cardiac death, TVMI, all-cause mortality, and stent thrombosis were comparable between both groups. Patients treated with DES-only were associated with a higher late lumen loss (0.42 ± 0.62 mm vs. 0.13 ± 0.42 mm, P < 0.001) compared with the DCB group at 1 year. In sensitivity analysis, the DCB group also presented a lower incidence of TLF, CD-TLR and stent thrombosis both compared to the two-stent strategy and compared to provisional stenting (Ps < 0.05).

Conclusion

The 2-year results of PCI utilizing DCB for LM true bifurcation lesions are superior to employing DES alone in terms of safety and effectiveness.

Is the world ready for the STICH 3.0 trial?

PURPOSE OF REVIEW

Coronary artery disease (CAD) is responsible for >50% of heart failures cases. Patients with ischemic left ventricular systolic dysfunction (iLVSD) are known to have poorer outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) compared to patients with a normal ejection fraction. Nevertheless, <1% of patients in coronary revascularization trials to date had iLVSD. The purpose of this review is to describe coronary revascularization modalities in patients with iLVSD and highlight the need for randomized controlled trial evidence comparing these treatments in this patient population.

RECENT FINDINGS

Network meta-analytic findings of observational studies suggest that PCI is associated with higher rates of mortality, cardiac death, myocardial infarction, and repeat revascularization but not stroke compared to CABG in iLVSD. In recent years, outcomes for patients undergoing PCI have improved as a result of advances in technologies and techniques.

SUMMARY

The optimal coronary revascularization modality in patients with iLVSD remains unknown. In observational studies, CABG appears superior to PCI; however, direct randomized evidence is absent and developments in PCI techniques have improved post-PCI outcomes in recent years. The Surgical Treatment for Ischemic Heart Failure 3.0 consortium of trials will seek to address the clinical equipoise in coronary revascularization in patients with iLVSD.