Bifurcation Lesions Research Articles

Impact of Medina classification on clinical outcomes of imaging-guided coronary bifurcation stenting

BackgroundIntracoronary imaging improves clinical outcomes after stenting of complex coronary bifurcation lesions (CBLs), but the impact of Medina classification-based CBL distribution on outcomes of imaging-guided bifurcation stenting is unclear. MethodsIn this integrated analysis of four previous studies, in which all CBLs were treated with drug-eluting stents under intravascular ultrasound or optical coherence tomography guidance, the distribution of 763 CBLs was assessed using angiographic Medina classification. Major adverse cardiac events (MACE), including target lesion revascularization (TLR), myocardial infarction, stent thrombosis, and cardiac death, were investigated at 1-year follow-up. ResultsThe most and least prevalent Medina subtypes were 0-1-0 (27.9 %) and 0-0-1 lesions (2.8 %). The most and least frequent MACE/TLR rates were 18.2 %/18.2 % for 0-0-1 lesions and 4.1 %/2.8 % for 0-1-0 lesions. Risks were higher for 0-0-1 lesions than for 0-1-0 lesions for both MACE (hazard ratio [HR]: 4.04, 95 % confidence interval [CI]: 1.21–13.45, p = 0.02) and TLR (HR: 6.19, 95 % CI: 1.69–22.74, p = 0.006). MACE rates were similar for true and non-true CBLs excluding 0-0-1 lesions (8.2 % and 5.9 %, HR 1.54, 95 % CI: 0.86–2.77, p = 0.15), while MACE (HR: 3.25, 95 % CI: 1.10–9.63, p = 0.03) and TLR (HR: 4.24, 95 % CI: 1.38–12.96, p = 0.01) risks were higher for 0-0-1 lesions. ConclusionsThis integrated analysis of imaging-guided bifurcation stenting demonstrated similar clinical outcomes in true and non-true CBLs, except for 0-0-1 lesions, which had a significantly higher risk of MACE/TLR.

Novel planned two-stent technique for bifurcation lesions: Inverted compression T-stenting.

Novel planned two-stent technique for bifurcation lesions: Inverted compression T-stenting.

Double kissing inflation outside the stent versus jailed balloon technique for coronary bifurcation lesions

Abstract Background Side branch (SB) occlusion remains challenging in percutaneous coronary intervention (PCI) for bifurcation lesions even in the era of jailed balloon technique (JBT). Our previous single-arm study introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of the protective balloon kissing with the stent balloon and post-dilation balloon. Objective To confirm whether DKo can protect SB better than JBT in a large sample of bifurcation lesions. Methods This retrospective, single-center cohort study enrolled 875 consecutive patients underwent bifurcation PCI either in DKo (n=209) or JBT group (n=666). The primary endpoint was transient SB loss after removal of the protective balloon. The secondary endpoints included rates of SB rewiring, final kissing balloon inflation (FKBI), SB stenting, final SB loss, and peri-procedural myocardial infarction (PMI). Results Transient SB loss occurred in only 1 patient (0.5%) in DKo but 32 patients (4.8%) in JBT (p<0.005). Transient loss in JBT group was triggered by rewiring (n=21), post-dilation (n=8) and severe dissection (n=3). DKo caused lower rates of rewiring (0.5% vs. 13.8%, p<0.001), FKBI (0.5% vs. 7.7%, p<0.001) and PMI (0.5% vs. 2.9%, p=0.045). SB stenting and final SB loss showed a lower tendency in DKo [0% vs. 0.8%, p=0.21; 0% vs. 1.2%, p=0.11]. DKo was the only protector against transient SB loss [odds ratio=0.08, 95% confidence interval (0.01-0.59), p=0.013]. Conclusion DKo protects SB better than JBT in PCI for bifurcation lesions. Randomized controlled studies are required to confirm the long-term benefit.

Impacts of illicit drug use on coronary angiographic findings in a multicenter registry of patients with acute coronary syndrome

Abstract Background Although illicit drug use may induce acute coronary syndrome (ACS), its impacts on coronary angiographic characteristics and the coronary artery disease (CAD) burden are a matter of debate. Purpose To assess the association between illicit drugs use and coronary angiographic findings in a multicenter patients with ACS. Methods From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1,499 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for ACS with an angiography analysed by an independent Angiographic Core Laboratory. Patients with history of coronary artery bypass graft surgery were excluded. We compared coronary angiographic findings between illicit drugs users and others for the following parameters: the prevalence, location, type, and severity of CAD obstruction (stenosis≥50%), SYNTAX score, residual SYNTAX score, and the characteristics of percutaneous coronary intervention (PCI). Results Among the 283 patients with ACS (62±13 years, 77% men), 38 (13.4%) had a positive test for illicit drugs (cannabis: 12%, cocaine: 1.1%, MDMA: 0.7%). Drug users were younger than other patients (51±12 vs 64±12 years, p<0.001), but there were no significant difference in sex ratio (89.5% vs 75.5%, p=0.088). There was no significant difference in the rate of STEMI (52.6% vs 45.7%, p=0.535) and NTSEMI (47.4% vs 54.3%, p=0.535) between drug users and others. Regarding the CAD burden, drug users had significantly less obstructive coronary lesions (1.6±1.1 vs 2.2±1.4, p=0.012), less multivessel obstructive CAD (31% vs 61%, p=0.001), and a trend for a lower initial SYNTAX score (8.3±7.8 vs 10.8±8.4; p=0.084) compared to others. Concerning culprit lesion, drug users had less bifurcation lesions (p=0.008), a trend for more left anterior descending (LAD) artery lesions (p=0.091), a higher thrombus burden score (p=0.057), and less lesions above 20 mm (p=0.183). Conclusion In patients with ACS, recent illicit drug use is associated with less number of significant lesions and less multivessel CAD. Concerning culprit lesions, illicit drugs use is associated with less bifurcation lesions, with a trend for more LAD lesions and a higher thrombus burden score.ACS analysed with Core LaboratoryAngiographic findings according to drug

Outcomes of drug eluting stents vs. drug eluting balloons. A single center experience

Abstract Introduction Drug eluting stents (DES) are considered the default treatment option in the current era of percutaneous coronary interventions (PCI). Nevertheless, the use of drug eluting balloons (DEB) remains highly relevant, especially in the setting of in stent restenosis (ISR), and de-novo small vessel disease or bifurcation lesions. Material and method Among 17,630 consecutive PCI procedures performed in our tertiary medical center between 2010 and 2021, we identified 16,435 procedures performed using DES and 1,195 using DEB. Endpoints included mortality and major adverse cardiac events [MACE: death, myocardial infarction (MI), target vessel revascularization (TVR), and coronary artery bypass surgery (CABG)] at 1 year. Propensity score matching was used to create a well-balanced cohort. Results and discussion: Mean age was similar (65.7±12.1 vs. 65.8±11.1, p=0.85), but less female patients (16.7% vs. 21.2%, p<0.01) were observed in the DEB group. DEB patients presented with higher rates of diabetes, hypertension, and prior CABG (62.1% vs. 48.1%, 84.9% vs. 73.2% and 18.3% vs. 10.1% respectively, p<0.01 for all), as compared to DES patients. There were also higher rates of PCI for bifurcation lesions and in-stent restenosis (18.3% vs. 15.1% and 56.0% vs. 7.8% respectively, p<0.01 for both) in the DEB group. After propensity and adjustment for confounders, 370 matched pairs were compared. 1-year MACE rates were significantly higher (HR-1.51, 95%CI 1.04-2.18, p=0.03) in the DEB group, as compared to the DES group. This was driven by higher MI (6.8% vs. 1.9%, p<0.01), TVR (20.5% vs. 11.4%, p<0.01) and CABG (12.2% vs. 7.3%, p=0.02) rates in the DEB group. Adjusted rates of 1-year mortality (HR-1.20, 95%CI 0.75-1.67, p=0.45) did not differ between the two groups. Conclusions Treatment with DEB was associated with increased MACE at 1-year, driven by higher rates of MI, TVR and CABG, as compared to DES.Freedom from MACE

Association between post-procedural and long-term functional outcomes of jailed side branches in stented coronary bifurcation lesions assessed with side-branch murray law-based quantitative flow ratio

Abstract Background In coronary bifurcation lesions treated with percutaneous coronary intervention (PCI) using a 1-stent strategy, the occurrence of side branch (SB) compromise may lead to long-term myocardial ischemia in the SB territory. Murray law-based quantitative flow ratio (μQFR) is a novel angiography-based approach estimating fractional flow reserve from a single angiographic view, and thus more feasible to assess SB compromise in routine practice. However, its association with long-term SB coronary blood flow remained unknown. Aim To explore the association between post-procedural SB μQFR and long term SB coronary blood flow in non-left main (LM) coronary bifurcation lesions receiving 1-stent strategy. Methods A total of 146 patients with 313 non-LM bifurcation lesions receiving 1-stent strategy with drug-eluting stents was included in this retrospective study. These lesions had post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in SBs, and documented angiographic images of index procedure and 6- to 24-month angiographic follow-up. The post-procedural SB μQFR was calculated. Long-term SB coronary blood flow was quantified with the TIMI grading system using angiograms acquired at angiographic follow-up. Results At follow-up, 8 (2.6%), 16 (5.1%), 61 (19.5%), and 228 (72.8%) SBs had a TIMI flow grade of 0, 1, 2, and 3, respectively. The incidences of SB TIMI flow grade <2 and <3 at follow-up both tended to decrease across the tertiles of post-procedural SB μQFR (TIMI flow grade <2: P=0.086; TIMI flow grade <3: P=0.052). In the multivariable logistic regression models, post-procedural SB μQFR was independently associated with SB TIMI flow grade <2 and <3 at follow-up, respectively (all P<0.05). The receiver operating characteristic curve analyses indicated that the area under the curve of post-procedural SB μQFR to identify SB TIMI flow grade <2 at follow-up was 0.6673 (95% CI, 0.5610-0.7737; P=0.0064), and the QFR limits to yield specificity and sensitivity >80% were 0.79 and 0.90, respectively. Conclusions Post-procedural SB μQFR in non-LM bifurcation stenoses was independently associated with impaired long-term SB coronary blood flow. Further investigations should focus on whether PCI optimization based on μQFR may contribute to improve SB flow in the long term.

A novel scoring system devised by an international large-scale coronary bifurcation registry to guide the optimal choice between the 1- and 2-stent strategy: the BIFURCAT Two-Stent (BTS) score

Abstract Background and Aims Previous studies used predefined criteria to evaluate the outcomes of two stents over one stent. We sought to devise a scoring system based on data-driven criteria for the guiding the optimal choice between two approaches. Methods We analyzed an international coronary bifurcation cohort with 2nd-generation drug-eluting stents, the combined insights from the unified RAIN and COBIS bifurcation registries (BIFURCAT) registry. The primary endpoint was major adverse cardiac events (MACE), a composite of death, myocardial infarction, and target lesion failure. Results We analyzed 5333 patients (mean age: 66.2 years; male: 76%; 1-stent: 82%). We found one clinical and five angiographic factors associated with lower MACE risk when two stents were implanted compared with one. We assigned one point per each component the patient was positive for and defined this as the BIFURCAT Two-Stent (BTS) score. The 2-stent strategy was associated with significantly higher MACE rate in the total patient cohort (HR: 1.49; 95% CI: 1.19-1.87; P<0.001) and BTS score<4 (HR: 2.04; 95% CI: 1.64-2.56; P<0.001). However, the two stents had a lower chance of MACE in BTS score≥4 (HR: 0.56; 95% CI: 0.35-0.89; P=0.014) with or without adjustment for baseline and procedural characteristics and antiplatelet therapy. Conclusions Approximately 80% of the patients had low (<4) BTS score that showed favorable outcomes with the 1-stent strategy. However, those with high BTS scores (≥4) proved favorable outcomes with the 2-stent strategy. The BTS score may be able to guide interventionists to select an optimal stenting strategy in bifurcation lesions.

Diagnostic accuracy of vessel fractional flow reserve compared to conventional diagnostic tools in patients with coronary artery stenosis

Abstract Background Wire-based fractional flow reserve (FFR) is currently the golden standard in a physiological assessment for intermediate coronary artery stenosis (CAS). However, the clinical advantage of FFR has been limited by its invasiveness. In the previous study with a small number of participants (334 patients), three-dimensional quantitative coronary angiography (3D-QCA)-based vessel FFR (vFFR) has shown non-inferiority to wire-based FFR in diagnostic accuracy. There has been no reports regarding the relationship between vFFR and other conventional physiological assessment tools. Methods The present study was a retrospective registry designed to evaluate the diagnostic accuracy of vFFR compared to the conventional reference standard (wire-based FFR ≤0.80). Between January 2019 and February 2022, patients with stable or unstable angina, and non-ST-elevation acute coronary syndrome who had undergone physiological assessments [wire-based FFR, instantaneous wave-free ratio (iFR), resting full-cycle ratio (RFR), and/or coronary computed tomography angiography-derived FFR (FFRCT)] before percutaneous coronary intervention were included for the present analysis. The exclusion criteria were ST-elevation myocardial infarction, previous coronary artery bypass grafting, cardiogenic shock, and adenosine intolerance. In the present study, we investigate the relationship between vFFR and conventional tools such as wire-based FFR, iFR, RFR, and/or FFRCT in patients with intermediate CAS, including multi-vessel disease, severe coronary calcium, in-stent restenosis, and hemodialysis. Results The study included 722 patients (mean age, 70±10 years; male, 80%) who underwent vFFR in 698 patients (97%), wire-based FFR in 711 (98%), iFR in 523 (72%), RFR in 109 (15%), and FFRCT in 48 (7%). Most patients presented stable angina (93%). In the present study, multi-vessel disease was identified only 20% of all. A total of 1108 target vessels were LAD in 549 (50%), LCx in 287 (26%), and RCA in 272 (24%), respectively. Bifurcation lesions and in-stent restenosis were present in 12% and 13%, respectively. The subjects were diagnosed several comorbidities, such as hypertension (77%), dyslipidemia (57%), diabetes mellitus (40%), and hemodialysis (12%). Overall, vFFR showed good correlations with wire-based FFR (r=0.70; p<0.001), IFR (r=0.57; p<0.001), and RFR (r=0.69; p<0.001). However, the correlation between vFFR and FFRCT was weak (r=0.36; p<0.001). Furthermore, vFFR had a good diagnostic accuracy (sensitivity, specificity, negative predictive value and positive predictive value; 81%, 88%, 82% and 87%, respectively) to identify the lesions with wire-based FFR≤0.80 (AUC, 0.87; 95% CI, 0.84-0.90; p<0.001). Conclusion In this large number cohort, the 3D-QCA based vFFR has a good correlation with wire-based FFR, and a high diagnostic accuracy to detect the lesion with FFR ≤ 0.80 even in patients with severe coronary calcification, in-stent restenosis, and hemodialysis.Scatter plotsBland-Altman plots

Impact of atrial fibrillation on mortality of patients undergoing bifurcation PCI

Abstract Background Patients with coronary bifurcation lesions represent a group with a greater risk of mortality when referred for e percutaneous coronary intervention (PCI). Aim We aimed to compare the clinical outcomes in patients with or without present atrial fibrillation (AF) undergoing bifurcation PCI. Methods Investigator-initiated prospective study of patients with stable coronary artery disease, with a significant angiographic bifurcation lesion defined as diameter stenosis ≥50% who were referred for a PCI. All patients were followed up by telephone contact and/or clinical visit at 30 days and then monthly for vital status. Cardiovascular (CV) death was defined as death with clearly determined cardiac origin or death from an unknown reason. Log-rank test was used to assess the difference in mortality between the two groups. Propensity-matching was performed to account for differences in age, sex, hypertension, dyslipidemia, diabetes, smoking, cancer, renal failure, LV ejection fraction, and SYNTAX score between the two groups. The primary endpoint was the incidence of all-cause and cardiovascular death. Results A total of 358 patients were included – 179 in each group. The mean age was 71.1 ± 9.6, 31% (112) were females, 32% (119) were smokers, 98% (353) -hypertensive, 92% (329) with dyslipidemia, 44% (156) -diabetics, 28% (99) had previous MI, mean EF was 51.9 ±10.8 %. After 1:1 propensity-score matching, baseline characteristics between the two groups were similar. Intervention vessel was LAD in 69% (n=247), LCx – 17% (62), RCA – 10% (37) of the patients. For a median follow-up time of 56.5 [39-110] months, total mortality was 40%, whereas CV death occurred in 30.5% (n=109) of the patients. Both all-cause and CV death were significantly higher in patients with AF - 64 (35.8%) versus 79 (44.1%); p=0.040, and - 47 (26.3%) versus 62 (34.6%); p=0.031, respectively. Furthermore, atrial fibrillation was revealed as an independent predictor of cardiovascular death in Cox-regression analysis, together with the following factors: AF – HR 1.704, 95%CI [1.156-2.510], p=0.007, age – HR 1.057, 95%CI [1.032-1.082], p<0.01; diabetes HR 1.556, 95%CI [1.059-2.2287], p=0.024; COPD HR 2.037 95%CI [1.328-3.123], p=0.001; EF –HR 0.968, 95% CI [0.950-0.987], p=0.001. Conclusion The presence of atrial fibrillation in patients with coronary bifurcation lesions referred for PCI is associated with higher all-cause and cardiovascular mortality.

MPI/FLI/CTA multi-modality imaging of atherosclerotic plaque with plexind1-targeted nanoparticles

Abstract M1 macrophage is one of important components which contribute to the progression of atherosclerotic plaques.[1]Previous research of our team showed that plexind1 was expressed more in atherosclerotic plaques at vascular bifurcation than those at straight site and co-localized with M1 macrophages. This study aims to develop a novel multimodal imaging platform by designing a nanoprobe targeting plexind1 to detect and monitor bifurcation lesion and provide detecting method for animal research. Methods A novel multimodal imaging agent,A12-Fe3O4-Cy7, was constructed by coupling superparamagnetic iron oxide nanoparticle (SPIONs) with cyanine 7 N-hydroxysuccin imide ester（Cy7）and nanobody A12 which could target plexind1 specifically. The physical and biological properties were evaluated. To assess the A12-Fe3O4-Cy7 recognition and monitoring for plaque,high-fat-fed 10-week and 20-week Apoe-/- atherosclerosis mouse models were imaged using MPI and FLI,and both 3D images were fused with CTA. HE,Prussian blue and plexind1 immunohistochemical staining were performed on mouse carotid tissue sections. Results The A12-Fe3O4-Cy7 was of favorable stability, biocompatibility（concentration< 200ug/ml) and targeting effect.It could detect, locate, and monitor atherosclerotic plaques at bifurcation of carotid artery in ApoE-/- mice accurately and sensitively, showing significantly higher MPI and FLI signals both in vivo and ex vivo compared with both themselves before nanoprobe injection and two control groups(n=3,p<0.05). FLI is more sensitive than MPI to detect high-fat-fed 10-week mouse plaques.The results were confirmed histologically. Conclusion A12-Fe3O4-Cy7 might serve as a method to detect plaques at the bifurcation by targeting plexind1 in vivo. Limitations MPI is tested only in mouse models presently and it requires combination with CT to provide anatomical information. Besides，there was no intervention on plexind1,so the mechanism of plexind1 in bifurcation plaque occurrence and progression is not illustrated clearly,which is worth exploring in the future.In vitro and vivo assessmentIn vivo and ex vivo imaging

Intracoronary imaging guided percutaneous coronary intervention of stent restenosis: does it make a difference?

Abstract Background In-stent restenosis (ISR) remains the most common cause of stent failure after percutaneous coronary intervention (PCI). Compared to coronary angiography (CA), intracoronary imaging (ICI) provides a more accurate and detailed characterization of the degree of ISR and may help identify the underlying pathophysiological mechanism. Although recommended in the European guidelines, the impact of ICI in clinical outcomes in ISR is still under discussion. Purpose Our study aimed to analyze and compare clinical outcomes between CA PCI (group 1 - G1) and ICI-guided PCI (Intravascular ultrasound (IVUS) or optical coherence tomography (OCT)) (group 2 - G2). Methods We performed a retrospective single-center review of all consecutive patients with ISR treated in our center from September 2014 to January 2022. Patients with acute stent thrombosis were excluded. Primary endpoint was defined as death by all causes and secondary endpoint as a composite of cardiovascular (CV) mortality, culprit ISR PCI and ischemic stroke. Results 130 patients were included (mean age 66.23 ± 11.832 years, 77.7% male and mean follow-up period (FUP) 48.70 ± 27.356 months). Mean left ventricular ejection fraction was 50.19 ± 10.509%, 66.2% had dyslipidemia, 45.3% hypertension, 38.5% diabetes, 36.2% heart failure and 29.2% previous multivessel PCI. A total of 142 ISR lesions from 136 arteries were treated and ICI was used in 37 (28.5%) patients (IVUS in 16 (12.3%) and OCT in 21 (16.2%)). The ISR coronary segment and pattern is described in Table 1. The mechanism for ISR was identified in 23 lesions. The most common indication for coronary angiography was stable angina in 34.6% and NSTEMI in 31.5% and ISR was the culprit in 128 (98.5%) of the cases. The groups were well matched regarding baseline characteristics and comorbidities. PCI strategy was more often drug-eluting stenting (DES) vs drug-coated balloon (DCB) in group 2 (DES 18.3% vs 51.4% and DCB 81.7% vs 43.2% in G1 and G2 respectively). And, as expected, treatment of bifurcation lesions was more frequent in group 2 (9.7% G1 vs 30.6% G2). During the FUP there were 10 (7.7%) CV deaths and 19 (14.6%) non-CV deaths (19 in G1 and 0 in G2). The composite outcome of CV mortality, ischemic stroke and culprit ISR PCI occurred in 19 (20.2%) patients in G1 and 1 (2.7%) patient in G2. The use of ICI was associated with reduced all-cause mortality (HR=0.667 [95% CI 0.584-0.760], p=0.011) and reduced composite outcome (B (95%CI): -0.251 (-0.455 - -0.046), p=0.017). No difference between IVUS or OCT was found. The PCI strategy (DES vs DCB), stent type, length or diameter were not predictors of outcomes. Conclusion In IRS PCI, the use of ICI compared to standard of care CA was associated with a reduction in all-cause mortality and composite outcome of CV mortality, culprit ISR PCI and ischemic stroke. The strategy of PCI differed with DES being used more frequently than DCB. No difference between IVUS or OCT was found.

Side branch closure in patients undergoing coronary bifurcation stenting with or without side branch predilatation

Abstract Background Considerable progress in the treatment of coronary bifurcation lesions has been achieved. Side branch pre-dilatation (SPPD) is a technique that is generally not recommended by the latest guidelines and consensus statements. The main reason is the risk of side branch (SB) dissection or vessel closure. Aim The aim of the current study is to explore the rates of SB closure in patients undergoing bifurcation PCI with or without SB pre-dilatation. Methods All patients with coronary bifurcation lesions treated between 2012 and 2022 were included in the prospective registry. For the current analysis, only patients with stable or unstable angina were included, with follow-up of at least two years. Patients with STEMI and left main stenosis were excluded. Propensity Score Matching (PSM) was performed to equalize the effects of the following characteristics: age, sex, diabetes, smoking, hypertension, dyslipidemia, renal failure, cancer, COPD, atrial fibrillation, left ventricular ejection fraction, and SYNTAX score. SB closure was defined as SB ostial stenosis ≥99% with TIMI 0-1 flow. Results 832 patients from the registry covered the criteria for the current analysis. After PSM, 324 matched couples remained, and 648 patients were analyzed. The demographic characteristics of SBP(+) and SBP (-) were well balanced, with no differences between groups – age 68±10 years, 71% males, 40% smokers, 47% with diabetes, 26% with previous MI, 53% with previous PCI, 4% after CABG, 12% with peripheral arterial disease, 13% with COPD, 32% with renal failure, 23% AFib, LVEF 55±10%. Patient with SBP(+) wad more CTOs (17% vs. 9%, p=0.003), longer lesions (42±21mm vs. 36±20mm, p<0.001) and more severe SB stenoses (68%±25% vs. 41%±31%, p<0.001). Among true bifurcation stenoses (Medina xx1 – 63%, 410/648), 88% were predilated. SB closure was non-significantly different in groups with SBPD and SBnPD (3.6% vs. 2.2%, p=0.272). Acute SB closure after stenting occurred at similar rates in SBPD and SBnPD groups (3.6% vs. 2.7%, p=0.505), without difference in rates of MI if SB was closed or not (n=10/17, 59% vs. n=227/631, 36%, p=0.058). The rate of periprocedural MI was not significantly different between groups with and without SB closure – 52% vs. 34%, p=0.066. At the end of the procedure, only 7 SBs were closed, 2 in the SBPD group and 5 in the SBnPD group (p=0.461). Conclusions The rates of final SB closure were numerically lower (but not significantly different) when SBPD was performed. SB closure did not translate into worse clinical outcomes.

Abstract 15380: Diagnostic Performance of Ultrasonic Flow Ratio versus Quantitative Flow Ratio for Assessment of Coronary Artery Stenosis

Introduction: Ultrasonic flow ratio (UFR) is a novel intravascular ultrasound (IVUS)-derived method for fast computation of fractional flow reserve (FFR) without pressure wires and adenosine. Aims: The aim of this study was to evaluate the diagnostic performance of UFR and compare it with angiography-based quantitative flow ratio (QFR), using FFR as the reference standard. Methods: Patients who underwent coronary angiography, IVUS and FFR were analyzed. UFR and QFR was computed offline in a central core-lab by independent analysts blinded to FFR. Results: A total of 111 paired comparisons between UFR, QFR and FFR from 56 patients were analyzed. UFR showed a numerically better correlation (r=0.83 vs. 0.79; p=0.27) and significant better agreement (standard deviation of the difference=0.07 vs. 0.08; p=0.02) with FFR than QFR. Diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio for UFR to predict FFR was 92% (95% CI: 85%-96%), 85% (95% CI: 71%-94%), 97% (95% CI: 89%-99%), 95% (95% CI: 83%-99%), 90% (95% CI: 82%-95%), 27.6 (95% CI: 7.0-108.4), and 0.16 (95% CI: 0.08-0.31), respectively. The area under curve for UFR to predict an FFR ≤ 0.80 was 0.94, is equivalent to QFR (difference=0.04; p=0.23), and higher than minimal lumen area (difference=0.09, p=0.006). Diagnostic accuracy was not significantly different in bifurcation lesions, nor in non-bifurcation lesions. Conclusions: The UFR showed good diagnostic concordance with FFR, equivalent to QFR. The good diagnostic performance of UFR provides a potentiality for the integration of physiological assessment and intravascular imaging in real-world clinical practice.

Abstract 15225: Hybrid Coronary Revascularization versus Percutaneous Coronary Intervention for True Left Main Bifurcation Lesions

Introduction: Hybrid coronary revascularization (HCR) is an alternative and feasible treatment for true left main bifurcation lesion. Aims: This study sought to compare the clinical outcomes of patients with true left main bifurcation lesions undergoing revascularization by HCR or percutaneous coronary intervention (PCI). Methods: This was a propensity-matched cohort study. From March 1, 2010, to March 31, 2018, 40 consecutive patients with true left main bifurcation lesions underwent HCR at Fuwai Hospital. These patients were matched 1:1 to 40 contemporaneous patients who underwent PCI. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of cardiac mortality, myocardial infarction, stroke, and repeat revascularization. Results: There were no differences in patient characteristics between the two groups. During a mean follow-up of 2 years, MACCE occurred in 12 patients (3 in the HCR group and 9 in the PCI group). Kaplan-Meier survival analyses indicated that the cumulative incidence of MACCE (log-rank test, p = 0.026) and repeat revascularization ( p = 0.011) in the HCR group were significantly lower than those in the PCI group. Conclusions: Compared with PCI, HCR demonstrated satisfactory mid-term outcomes in MACCE for true left main bifurcation lesions.

Sex-Specific Differences in Clinical Outcomes in Patients With Coronary Bifurcation Lesions.

Coronary bifurcation lesions are frequent challenging findings during percutaneous coronary intervention (PCI). Contemporary evidence has explored the potential sex-specific differences in patients undergoing PCI. In the present meta-analysis, we compared clinical outcomes of patients undergoing bifurcation PCI between women and men. Using the random-effects method, we compared the clinical outcomes of patients with a coronary bifurcation lesion following PCI between women and men. The results were reported using relative risk (RR) and 95% confidence interval (CI). Baseline comorbidities and mean age were compared between the 2 studied groups. Four observational studies comprising 30,684 patients (8898 women and 21,786 men) were included in the meta-analysis. Women were significantly older than men with a relatively higher prevalence of baseline comorbidities. After using adjusted data from 2 out of 4 available studies, performing PCI for bifurcation lesions in women was not associated with an increased risk of mortality (RR 1.33, 95% CI, 0.78-2.29), myocardial infarction (RR 1.22, 95% CI, 0.41-3.61), target lesion revascularization (RR 1.06, 95% CI, 0.40-2.81), stent thrombosis (RR 0.99, 95% CI, 0.09-10.52), and stroke (RR 1.19, 95% CI, 0.64-2.22). Women were at higher risk of major bleeding compared to male counterparts (RR 2.23, 95% CI, 1.73-2.89). The present study showed no difference in the risk of adverse clinical outcomes except the risk of bleeding between genders with coronary bifurcation lesions. Future studies with adjustment of age and baseline comorbidities are needed to confirm these findings.

Long-Term Evaluation of Revascularization Strategies for Medina 0.1.0 Left Main Bifurcation Lesions: The LM-CROSSOVER Registry.

The present study aimed to compare long-term outcomes of patients with Medina 0.1.0 left main (LM) bifurcation lesions treated by crossover stenting (COS) versus accurate ostial stenting (AOS). A total of 229 consecutive eligible patients with Medina 0.1.0 LM bifurcation lesions were enrolled and were stratified according to the stenting techniques. The primary end-point was major cardiovascular and cerebral events (MACCE), defined as the combination of all-cause death, target vessel related-myocardial infarction (MI), clinically driven target lesion revascularization (TLR), stroke, or stent thrombosis. COS and AOS were applied to 78 (34%) and 151 (66%) patients, respectively. During a mean of 40.6 ± 21.1months of follow-up, the rate of MACCE (27.8 vs 12.8%; P=.007) was higher in patients treated with AOS than those treated with the COS technique, mainly driven by more frequent all-cause death (13.9 vs 3.8%, P = .013) and TLR (6.4 vs 15.9%; P = .029). In multivariable Cox regression analysis, AOS strategy was one of the independent predictors of MACCE (odds ratio: 2.166; 95% confidence interval, 1.080-4.340; P = .029). The current study suggests that COS was associated with a better long-term MACCE rate and lower all-cause mortality rate than AOS in patients with Medina 0.1.0 LM bifurcation disease.

High triglyceride-glucose index predicts cardiovascular events in patients with coronary bifurcation lesions: a large-scale cohort study

BackgroundCoronary bifurcation lesion, as a complex coronary lesion, is associated with higher risk of long-term poor prognosis than non-bifurcation lesions. The triglyceride-glucose (TyG) index has been shown to predict cardiovascular (CV) events in patients with coronary artery disease (CAD). However, the prognostic value of the TyG index in patients with bifurcation lesions who are at high risk of CV events remains undetermined. Therefore, this study aimed to investigate the association between the TyG index and CV events in patients with bifurcation lesions.MethodsA total of 4530 consecutive patients with angiography-proven CAD and bifurcation lesions were included in this study from January 2017 to December 2018. The TyG index was calculated as Ln [fasting triglyceride (mg/dL) × fasting plasma glucose (mg/dL)/2]. Patients were assigned into 3 groups according to TyG tertiles (T) (T1: <8.633; T2: 8.633–9.096 and T3: ≥9.096). The primary endpoint was CV events, including CV death, nonfatal myocardial infarction and nonfatal stroke at 3-year follow-up. Restricted cubic spline (RCS) analysis, Kaplan-Meier curves and Cox proportional hazard models were used to investigate the associations between the TyG index and study endpoints.ResultsDuring a median follow-up of 3.1 years, 141 (3.1%) CV events occurred. RCS analysis demonstrated a linear relationship between the TyG index and events after adjusting for age and male sex (non-linear P = 0.262). After multivariable adjustments, elevated TyG index (both T2 and T3) was significantly associated with the risk of CV events (hazard ratio [HR], 1.68; 95% confidence interval [CI],1.06–2.65; HR, 2.10; 95%CI, 1.28–3.47, respectively). When study patients were further stratified according to glycemic status, higher TyG index was associated with significantly higher risk of CV events in diabetic patients after adjusting for confounding factors (T3 vs. T1; HR, 2.68; 95%CI, 1.17–6.11). In addition, subgroup analysis revealed consistent associations of the TyG index with 3-year CV events across various subgroups. Furthermore, adding the TyG index to the original model significantly improved the predictive performance.ConclusionsHigh TyG index was associated with CV events in patients with bifurcation lesions, suggesting the TyG index could help in risk stratification and prognosis in this population.

Murray law-based quantitative flow ratio to assess left main bifurcation stenosis: selecting the angiographic projection matters.

Murray law-based quantitative flow ratio (µQFR) assesses fractional flow reserve (FFR) in bifurcation lesions using a single angiographic view, enhancing the feasibility of analysis; however, accuracy may be compromised in suboptimal angiographic projections. FFRCT is a well-validated non-invasive method measuring FFR from coronary computed tomographic angiography (CCTA). We evaluated the feasibility of µQFR in left main (LM) bifurcations, the impact of the optimal/suboptimal fluoroscopic view with respect to CCTA, and its diagnostic concordance with FFRCT. In 300 patients with three-vessel disease, the values of FFRCT and µQFR were compared at distal LM, proximal left anterior descending artery (pLAD) and circumflex artery (pLCX). The optimal viewing angle of LM bifurcation was defined on CCTA by 3-dimensional coordinates and converted into a 2-dimensional fluoroscopic view. The best fluoroscopic projection was considered the closest angulation to the optimal viewing angle on CCTA. µQFR was successfully computed in 805 projections. In the best projections, µQFR sensitivity was 88.2% (95% CI 76.1-95.6) and 84.8% (71.1-93.7), and specificity was 96.8% (93.8-98.6) and 97.2% (94.4-98.9), in pLAD and pLCX, respectively, with regard to FFRCT. The AUC of µQFR for predicting FFRCT ≤ 0.80 tended to be improved using the best versus suboptimal projections (0.94 vs. 0.89 [p = 0.048] in pLAD; 0.94 vs. 0.88 [p = 0.075] in pLCX). Computation of µQFR in LM bifurcations using a single angiographic view showed high feasibility from post-hoc analysis of coronary angiograms obtained for clinical purposes. The fluoroscopic viewing angle influences the diagnostic performance of physiological assessment using a single angiographic view.

Outcomes of Provisional Stenting With Versus Without Side Branch Intervention in Patients With Bifurcation Lesion–Related ST-Segment Elevation Myocardial Infarction

To date, the best approach to coronary bifurcation lesion remains unsettled, and the parameters to guide side branch ballooning or stenting are not yet defined. This study aimed to compare the survival outcomes after provisional stenting with versus without side branch intervention. A cohort was conducted on 132 patients who underwent coronary angiography at Toulouse University Hospital for ST-segment elevation myocardial infarction with large culprit nonleft main coronary bifurcation lesion. Study participants were divided into 2 groups depending on the performance or not of a side branch intervention. We observed the living status at 1-year after hospital discharge. Side branch intervention by balloon inflation or final balloon kissing technique was performed in 34.1% of study participants. At 1-year follow-up, the incidence of all-cause mortality was 7.8 per 100 person-years (95% confidence interval [CI] 4.1 to 15), and although it seemed higher in the side branch intervention group (10 per 100 person-years [95% CI 3.8 to 26.7] vs 6.6 per 100 persons-years [95% CI 2.8 to 15.9]), the survival analyses showed no differences in survival outcomes (hazard ratio side branch intervention 1.55 [0.42 to 5.78], p=0.513). In conclusion, in the setting of a coronary bifurcation causing ST-segment elevation myocardial infarction, simple provisional stenting without side branch intervention showed a low mortality rate and no differences in the 1-year survival outcomes.

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 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. 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. ClinicalTrials.gov no. NCT05731687.