Side branch FFR after provisional stenting: simplified approach based on OCT frame count

Background/Introduction

Treatment of bifurcation coronary artery lesions remains a major challenge in interventional cardiology. Side branch (SB) stenoses are frequently observed after stent implantation in bifurcation lesions, although angiographically narrowed SBs may not be functionally significant. Fractional flow reserve (FFR), a pressure-derived index of the hemodynamic significance of a coronary artery stenosis, may be useful in determining whether additional intervention is required in jailed SBs. Angiography and intravascular ultrasound (IVUS) derived parameters have showed poor diagnostic accuracy in predicting the functional significance of jailed SBs.

Purpose

The aim of the present study was to use high resolution optical coherence tomography (OCT) imaging to predict functionally significant SB stenoses after provisional stenting defined as SB FFR ≤0.80.

Methods

Seventy-one patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses undergoing provisional stenting were enrolled in the prospective study. OCT pullbacks were performed before and after stent placement, and SB FFR was measured after main vessel stenting. SB ostium area (SBOA) was assessed using three-dimensional OCT cut-plane analysis off-line. In addition, we developed a simplified approach to SB ostium assessment based on SB ostium frame count using two-dimensional OCT pullback not requiring off-line 3D reconstruction. For the analysis, consecutive frames were counted between the most distal and most proximal take-off of the SB frames.

Results

Similar to previous studies, quantitative coronary angiography findings were not associated with the functional significance of SBs after main vessel stenting. In contrast, SBOA assessed by 3D-OCT after provisional stenting strongly correlated with post-procedure SB FFR. The optimal cut-off value for the SBOA area to predict a SB FFR ≤0.80 was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve of 0.92 (95% CI: 0.84–0.99). A simplified approach to SB ostium assessment using OCT frame count yielded a sensitivity of 82%, specificity 89% and area under the curve 0.92 (95% CI: 0.84 to 0.99) with a cut-off of 4.5 frames allowing detection of functionally significant SB stenoses during the procedure in real time. Figure 1 shows a receiver-operating characteristic curve for SB FFR ≤0.8 and a representative case with SB FFR = 0.66 after provisional stenting and SB ostium frame count equal 3 (Frame 1 to 3)

Conclusion(s)

Assessment of SB using either 3D OCT off-line reconstruction or a simplified approach based on OCT frame count can detect SB branches with FFR ≤0.80 with high sensitivity and specificity. The developed approaches may represent a useful tool to assess provisional stent outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific; St. Jude Medical

Developing a fully 3d animated educational application to teach bifurcation lesion treatment

Background

Coronary bifurcation lesions make up around 15 to 20 percent of interventions. Especially for younger interventionalists, they pose a steep difficulty curve due to the daunting set of ways treatment can diverge from the initial plan based on plaque shift or other complications.

Purpose

BifurcAID 3D was designed to intuitively show some of the key phenomena during bifurcation lesion treatment. Plaque shift, the importance of proximal optimization, the opening of a jailed side branch, and the overlapping layers of stent in the Culotte technique are among some of the aspects of bifurcation lesion treatment that can benefit from a clear visual format.

Methods

Iterating on the bifurcation algorithm developed at a high volume metropolitan PCI center, this fully animated application has many branching points where plaque shift is assessed and the treatment plan and animation varies accordingly to show reactive balloon angioplasty, stenting, or entirely switching to dedicated two stent techniques.

Results

The resulting application is an easy-to-navigate algorithm for left and non left main bifurcation lesion treatment with fully animated clear depictions of bifurcation lesion treatments including provisional, bail-out strategies, and dedicated two stent techniques alongside descriptive text.

Conclusions

Creating free educational content for aspiring and current physicians serves to elevate the field and lower the barriers to entry. BifurcAID 3D will make available intuitive education on complex bifurcation lesion treatment worldwide.

Representative Images of BifurcAID 3D

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Education Grant

Side branch fractional flow reserve after provisional stenting of calcified bifurcation lesions: The ORBID-FFR study

OBJECTIVES

We examined the incidence of side branch (SB) compromise after provisional stenting of calcified bifurcation lesions treated with rotational atherectomy (RA) or cutting balloon angioplasty (CBA) and the utility of optical coherence tomography (OCT) to detect functionally significant SB stenoses.

BACKGROUND

The comparative impact of RA versus CBA on SB compromise and functional significance remains poorly characterized.

METHODS

Seventy-one consecutive patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses were randomized to RA (n = 35) or CBA (n = 36). The primary endpoint was SB compromise defined as SB diameter stenosis ≥70%, SB dissection or thrombolysis in myocardial infarction flow grade < 3 after provisional stenting. Secondary endpoints included SB FFR in noncompromised SBs and its correlation with SB ostium area (SBOA) assessed by three-dimensional OCT.

RESULTS

SB compromise after provisional stenting was observed in 7 (20.0%) lesions that underwent RA and in 9 (25.0%) lesions treated with CBA (p = .62). Mean SB FFR was 0.83 ± 0.08 and was similar between the study arms. Functionally significant SB stenosis (FFR ≤ 0.80) was detected in 17(30.9%) angiographically noncompromised SBs. SBOA after stenting was an independent predictor of FFR ≤ 0.80 (OR 0.002, 95% CI: 0.00-0.15, p = .002). The optimal cutoff value for SBOA to predict functionally significant SB stenosis was 0.76 mm² (sensitivity 82%, specificity 89% and area under the curve 0.92, 95% CI: 0.84-0.99).

CONCLUSIONS

The rates of SB compromise and functionally significant stenosis after provisional stenting of calcified bifurcation lesions were similar between two lesion preparation strategies. OCT SBOA can detect SB branches with FFR ≤ 0.80 with high sensitivity and specificity.

Intravascular Brachytherapy for the Management of Repeated Multimetal-Layered Drug-Eluting Coronary Stent Restenosis

BACKGROUND

Because of the widespread acceptance of percutaneous coronary intervention with drug-eluting stents as an effective treatment strategy for in-stent restenosis, it is common to encounter multimetal layer stent restenosis in the recent years. This study aimed to evaluate the clinical outcomes of such patients treated with intravascular brachytherapy (IVBT) in comparison with other percutaneous options.

METHODS AND RESULTS

We enrolled patients who underwent percutaneous coronary intervention during the period between 2011 and 2015 for recurrent drug-eluting stents in-stent restenosis with at least 2 layers of stents at the lesion site. This analysis compared patients who underwent treatment with IVBT and those who did not (non-IVBT group). The primary end point measured was major adverse cardiac events defined as a composite of target lesion revascularization, myocardial infarction, and all-cause mortality at 12 months. Adjusted associations were measured using propensity score matching. A total of 328 percutaneous coronary intervention patients met the eligibility criteria, of which 197 patients received IVBT, and 131 patients underwent routine percutaneous intervention. The primary end point was significantly lower in patients undergoing IVBT (13.2% and 28.2%; P=0.01). A propensity score matching for risk factors of in-stent restenosis identified 182 patients. The advantages of IVBT with regard to 1-year major adverse cardiac events were confirmed in this matched cohort (13.2% and 30.8%; adjusted hazard ratio [95% CI]: 0.37 [0.18-0.73]; P<0.01).

CONCLUSIONS

In this analysis, IVBT led to significantly lower major adverse cardiac events in patients with multilayered drug-eluting stents restenosis when compared with other percutaneous options at 1-year follow-up.

Treatment strategies for coronary bifurcation lesions made easy in the current era by introduction of the BIFURCAID app

Coronary bifurcation lesions account for 15-20% of all percutaneous coronary interventions. Percutaneous revascularization of these lesions is technically challenging and results in lower success rates than nonbifurcation lesions. There are unique procedural considerations and techniques that are employed in the percutaneous revascularization of these lesions. Our objective is to define the procedural complexities of treating coronary bifurcation lesions and describe the leading provisional and dedicated two stent techniques used to optimize procedural and clinical results, as described in the BIFURCAID app.

Real-World Bioresorbable Vascular Scaffold Experience Compared With Second-Generation Metallic Drug-Eluting Stents in Complex Coronary Lesions

OBJECTIVES

The aim of the study was to compare the acute outcomes of Absorb bioresorbable vascular scaffolds (BVS) and second-generation drug-eluting stent (DES) implantation in routine clinical practice. There is a paucity of data regarding BVS use in a real-world patient population.

METHODS

The study population comprised 40 consecutive patients who underwent percutaneous coronary intervention (PCI) with BVS implantation at a tertiary-care center in New York, New York between July and December of 2016. An optimal implantation technique including adequate lesion preparation, mandatory postdilation, and optical coherence tomography (OCT) imaging was used in all cases. De novo lesions treated with BVS were compared to lesions treated with DES matched by OCT calcium arc, scaffold/stent size, use of atherectomy device, and lesion postdilation. Acute lumen gain, minimal device area, malapposition, eccentricity, and symmetry index were assessed using OCT.

RESULTS

We analyzed OCT images of 40 BVS cases and 40 matching DES cases from 35 and 40 patients, respectively. Compared to the DES group, the BVS group demonstrated similar acute lumen gain, minimal scaffold/stent area, eccentricity index, and symmetry index after PCI. There were fewer malapposed struts detected after BVS implantation; however, malapposition distance and length were not different between the groups.

CONCLUSION

BVS implantation in a real-world patient population with optimal implantation technique resulted in similar stent expansion and better strut apposition compared to DES implantation.

Prognostic Relation Between Severity of Diabetes Mellitus (On or Off Insulin) ± Chronic Kidney Disease with Cardiovascular Risk After Percutaneous Coronary Intervention

The presence of either diabetes mellitus (DM) or chronic kidney disease (CKD) is associated with a worse prognosis after percutaneous coronary intervention (PCI). It is also known that outcomes in patients treated with insulin (insulin requiring type 2 diabetes mellitus [ITDM]) are worse than those who are not on insulin (non-insulin type 2 diabetes mellitus [NITDM]). We sought to compare long-term outcomes in patients who underwent PCI with varying severity of DM with and without CKD. We retrospectively studied 17,898 patients who underwent PCI from January 2009 to December 2014 in the Mount Sinai Cath Lab. Patients were categorized into groups by the presence or the absence of CKD and by the DM status (none, NITDM, or ITDM). In the absence of CKD, adjusted hazard ratios (95% confidence interval [CI]) for death or myocardial infarction associated with NITDM and ITDM were 1.65 (95% CI 1.02 to 2.67) and 3.78 (95% CI 2.23 to 6.40), respectively. Analogous risks in the presence of CKD were 3.34 (95% CI 1.99 to 5.61) and 6.26 (95% CI 3.84 to 10.2). This study shows that irrespective of renal status, the need for insulin in the setting of DM identifies a group with substantial risk of death or myocardial infarction at 1 year.

Intracoronary Imaging, Cholesterol Efflux, and Transcriptomics after Intensive Statin Treatment in Diabetes

Residual atherothrombotic risk remains higher in patients with versus without diabetes mellitus (DM) despite statin therapy. The underlying mechanisms are unclear. This is a retrospective post-hoc analysis of the YELLOW II trial, comparing patients with and without DM (non-DM) who received rosuvastatin 40 mg for 8–12 weeks and underwent intracoronary multimodality imaging of an obstructive nonculprit lesion, before and after therapy. In addition, blood samples were drawn to assess cholesterol efflux capacity (CEC) and changes in gene expression in peripheral blood mononuclear cells (PBMC). There was a significant reduction in low density lipoprotein-cholesterol (LDL-C), an increase in CEC and beneficial changes in plaque morphology including increase in fibrous cap thickness and decrease in the prevalence of thin cap fibro-atheroma by optical coherence tomography in DM and non-DM patients. While differential gene expression analysis did not demonstrate differences in PBMC transcriptome between the two groups on the single-gene level, weighted gene coexpression network analysis revealed two modules of coexpressed genes associated with DM, Collagen Module and Platelet Module, related to collagen catabolism and platelet function respectively. Bayesian network analysis revealed key driver genes within these modules. These transcriptomic findings might provide potential mechanisms responsible for the higher cardiovascular risk in DM patients.

Incidence of Renal Failure Requiring Hemodialysis Following Transcatheter Aortic Valve Replacement

OBJECTIVE

Studies have shown that iodinated radiocontrast use is associated with acute renal failure especially in the presence of chronic kidney disease and multiple factors modulate this risk. The purpose of this meta-analysis is to compare the incidence of renal failure requiring hemodialysis between transfemoral (TF) and transapical (TA) transcatheter aortic valve replacement using the Edwards valve.

METHODS

The PubMed database was searched from January 2000 through December 2014. A total of 10 studies (n = 2,459) comparing TF (n = 1,268) and TA (n = 1,191) TAVR procedures using the Edwards valve were included. Variables of interest were baseline logistic EuroSCORE, prevalence of diabetes mellitus, hypertension, peripheral arterial disease, chronic kidney disease and amount of contrast used. The primary endpoint was incidence of renal failure requiring hemodialysis. The odds ratio and 95% CI were computed and P < 0.05 was considered as the level of significance.

RESULTS

The logistic EuroSCORE was significantly higher in TA compared to TF (P = 0.001) TAVR. The amount of contrast (mL) used was significantly higher in the TF group compared to the TA group (mean difference: 36.9, CI: 25.7-48.1, P < 0.001). The incidence of hemodialysis following the procedure was significantly higher in the TA group compared to TF group (odds ratio = 4.3, CI: 2.4-7.8, P < 0.00001).

CONCLUSIONS

This meta-analysis suggests that despite the lower amount of contrast used in TA-TAVR, the incidence of renal failure requiring hemodialysis was higher with the Edwards valve. This suggests that the incidence of renal failure requiring hemodialysis after TAVR is associated with baseline comorbidities in the TA-TAVR group rather than the volume of contrast used.

Abstract 153: Post-procedural New Onset Atrial Fibrillation in Patients Undergoing Transcatheter Aoritc Valve Implantation versus Surgical Aortic Valve Replacement for Severe Aortic Stenosis: A Meta-analysis

Background: Transcatheter aortic valve implantation (TAVI) is performed in patients with severe aortic stenosis who are not a candidate for surgical aortic valve replacement (SAVR). New onset post-operative atrial fibrillation is a common complication after SAVR and has also been reported after TAVI in clinical trials and registries. The objective of this meta-analysis is to compare incidence of post-procedural new onset atrial fibrillation in patients who underwent TAVI versus SAVR.

Methods: PubMed and the Cochrane Center Register of Controlled Trials were searched through January 2015. Six studies (n= 1173) which reported incidence of post-procedural new onset atrial fibrillation comparing TAVI (n=596) and SAVR (n=577) were included. End point was post-procedural new onset atrial fibrillation. The odds ratio (OR) with 95% confidence interval (CI) was computed and p<0.05 was considered as a level of significance.

Results: The studies were homogeneous. Incidence of post-procedural new onset atrial fibrillation was significantly higher in SAVR group compared to TAVI group (OR: 3.10, CI: 2.20-4.35, p<0.00001) (Figure 1).

Conclusion: The results of this meta-analysis of 1173 patients suggest that SAVR is associated with higher incidence of post-procedural new onset atrial fibrillation compared to TAVI procedure. This complication may lead to significant morbidity due to need of long term anticoagulation as well as possibility of tachycardia induced cardiomyopathy; however, randomized controlled studies are needed to further evaluate the long-term clinical outcomes.

Abstract 367: Measurement of Lumen Dimensions in Non-stented and Stented Coronary Arteries: A Meta-analysis of Frequency Domain Optical Coherence Tomography versus Intravascular Ultrasound

Background: Intraluminal coronary morphology is traditionally evaluated by Intravascular Ultrasound (IVUS). Frequency Domain Optical Coherence Tomography (FD-OCT) is a novel method for evaluation of coronary lumen dimensions. Current literature has paucity of data with limited sample size comparing FD-OCT to IVUS. The objective of this meta-analysis is to compare the FD-OCT versus IVUS in assessment of lumen dimensions in non-stented and stented coronary arteries.

Methods: PubMed and the Cochrane Center Register of Controlled Trials were searched through January 2015. Seven studies (n=169 vessels) comparing FD-OCT versus IVUS procedures in assessing lumen dimensions in non-stented and stented coronary arteries were included. Outcomes were minimum lumen area, minimum lumen diameter and maximum lumen diameter. The mean difference (MD) with 95% confidence interval (CI) was computed and p<0.05 was considered as a level of significance.

Results: FD-OCT measured significantly smaller minimum lumen area and maximum lumen diameter compared to IVUS in non-stented vessels (MD: -0.86 mm 2 , CI: -1.18 to -0.55, p<0.00001 and MD: -0.21 mm, CI: -0.35 to -0.06, p=0.006, respectively). Minimum lumen diameter was not significantly different between two groups in non-stented coronary arteries (p=0.21). In stented vessels, no significant difference was found in measurement of minimum lumen area (p=0.34) and minimum lumen diameter (p=0.41) between FD-OCT and IVUS.

Conclusion: The results of this study suggest that FD-OCT maybe a better modality to evaluate the severity of stenosis in non-stented coronary arteries. FD-OCT is comparable to IVUS in measuring lumen dimensions in stented vessels.

Abstract 364: Comparison Between Frequency Domain Optical Coherence Tomography and Intravascular Ultrasound in Detecting Mechanical Complications of Coronary Stent Implantation: A Meta-analysis

Background: Frequency Domain Optical Coherence Tomography (FD-OCT) is a novel method for evaluation of complications related to stent. Current literature has paucity of data with limited sample size comparing FD-OCT to Intravascular ultrasound (IVUS). The objective of this meta-analysis is to compare FD-OCT to IVUS in evaluation of mechanical complications after stent implantation.

Methods: PubMed was searched through January 2015. Four studies (n=95 vessels) comparing FD-OCT to IVUS procedures to determine mechanical complications of coronary artery stent placement were included. End points were detection of intraluminal thrombus, edge dissection, malapposition, and malapposition area. The mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI) was computed as appropriate and p<0.05 was considered as a level of significance.

Results: FD-OCT detected significantly more complications including intraluminal thrombus (OR: 5.15, CI: 1.06-24.89, p=0.04), edge dissections (OR: 6.10, CI: 2.11-17.68, p=0.0009) (figure A) and malapposition (OR: 4.83, CI: 2.21-10.99, p<0.0002) (figure B) compared to IVUS. Malapposition area measurement was not different between two modalities (p=0.27).

Conclusion: The results of our meta-analysis suggest that FD-OCT is a better intravascular imaging modality compared to IVUS in detecting mechanical complications after coronary artery stent implantation. Additionally, this study suggests that FD-OCT and IVUS are comparable in detecting malapposition area.