Left Main Research Articles

Abstract 12181: Targeted Intra-Coronary Delivery versus Intra-Myocardial Injection of Therapeutics for Myocardial Recovery: A Nanoparticle Image Guided Porcine Study

Introduction: The optimal cardiac delivery route for stem cell and gene therapeutics is poorly understood. Direct intramyocardial (IM) injection has been proposed as the gold standard, however, it is invasive and not studied in detail against targeted intra-coronary (IC) delivery techniques. We sought to compare effectiveness of IM and targeted IC methods using cardiac magnetic resonance imaging (CMR) of nanoparticles in a porcine model. Hypothesis: IM provides the highest retention of delivered therapeutic, while targeted IC delivery yields high-volume retention in the perfused coronary territory. Methods: In Yorkshire swine (n=10), 5ml of ferumoxytol iron oxide (IO) nanoparticles, similar in size to therapeutic viral vectors, were injected: 1) IM via thoracotomy (n=3), 2) catheter based IC balloon-occlusion (BO) with distal infusion of the LAD (n=4), 3) IC with perforated balloon side wall (SW) infusion in the LAD (n=2), or 4) IC non-selective left main (LM) (n=1). Hearts were harvested and imaged with CMR using T1 and 3D inversion-recovery sequences. Retention of nanoparticles was quantified by percent of myocardium occupied. Results: IM delivery yielded the highest retention (16.3±5.5% of myocardial volume, p=0.04). Of the IC approaches, BO had the highest retention (8.7±2.2%, p=0.13 vs IM) compared to SW (5.5±4.9%) and LM (0%). On 3D CMR, BO yielded consistent uptake in the distal LAD territory, including the anterior wall and septum. IM delivery was limited to the anterior wall with no nanoparticles in the septum. Troponin increased 15,600±4,910 with IM vs.184±262 with IC (p=0.14). Conclusions: Direct IM injection offers the highest retention of delivered therapeutics to the heart. IC balloon occlusion-distal infusion has highest retention among IC techniques and provides an effective approach to direct therapeutics to the vascular bed most impacted by an infarct.

Abstract 12376: Coronary Artery Bypass Graft Surgery in Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome. While most patients are managed conservatively, some patients may require percutaneous or surgical revascularization. Limited data exist on SCAD patients referred for coronary artery bypass graft (CABG) surgery. Hypothesis: Examine the clinical characteristics, management, and outcomes of SCAD patients referred for CABG. Methods: Retrospective study of patients enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who underwent CABG during the initial management of acute SCAD episode. Results: Among the 81 patients with SCAD referred for CABG, 3 (4%) were men, mean age was 40.6 +/- 8.4 years; the majority were white (91%), and 24 (30%) had pregnancy-associated SCAD (P-SCAD). The most common presenting symptom was chest pain 80 (99%); 57 (70%) presented with ST elevation myocardial infarction (STEMI), and 21 (26%) presented with non-ST elevation MI. Multivessel dissection occurred in 40 (49%), left anterior descending artery (LAD) involvement occurred in 66 (81%) and left main (LM) in 32 (40%). Left ventricular ejection fraction was <50% in 40 patients (49%) at time of initial SCAD. The most common reasons for CABG were the presence of high-risk anatomy (56%), hemodynamic instability/active ischemia (7%), failed PCI (9%), and other/unknown (12%). Most patients received venous plus arterial bypass grafts 42 (52%), saphenous vein grafts in 20 (25%), and left internal mammary artery in 17 (21%). Screening for underlying arteriopathy was performed in 50 (62%) of whom 29 (36%) had fibromuscular dysplasia. Recurrent SCAD occurred in 10 (12%) after an average of 6.2 +/- 5 years after initial SCAD. Of those with recurrent SCAD, none required repeat surgical revascularization and 6 required percutaneous intervention (PCI). There were no deaths. Conclusions: Patients undergoing CABG for SCAD commonly present with STEMI, LM, or multivessel dissection, and failed percutaneous intervention attempts. In addition, CABG for P-SCAD was more frequent than expected and may relate to the increased prevalence of multivessel dissection. CABG was associated with low mortality, but recurrent SCAD may still occur.

Abstract 11699: Angiographic Coronary Artery Disease (CAD) and Outcomes in Acute Heart Failure (HF)

Introduction: The association between CAD severity and long-term outcomes in patients admitted with acute HF has not been determined. We characterized the angiographic burden of CAD in patients with acute HF and determined the association between CAD severity and mortality and readmission outcomes. Methods: In a multicenter registry of 70 hospitals in Ontario, Canada, we identified acute HF patients who underwent coronary angiography within 14 days of hospitalization (April 2010-March 2013) using stratified random sampling. We selected a cohort of HF patients with a higher a priori risk of CAD, defined inclusively as those with at least one of the following features: previous myocardial infarction (MI), troponin elevation, or angina on presentation. Using angiographic data, we defined obstructive CAD as the presence of > 70% stenosis in at least one epicardial vessel or > 50% left main (LM) stenosis. Multivessel disease (MVD) was defined as the presence of obstructive disease in 2 or more vessels. We determined adjusted associations between coronary anatomy and the rate of cardiovascular (CV) death and readmissions over two years. Results: Of 1772 patients undergoing angiography who met inclusion criteria (median age 71 [IQR 62-79] years; 38.5% women), 1039 patients had CAD and 683 had MVD. Increasing CAD burden was associated with higher CV death (Figure). CV death was significantly increased in those with any CAD and HFpEF (HR 2.27, 95%CI; 1.12, 4.59, p=0.023). The rate of CV death was increased in MVD (HR 1.91, 95% CI; 1.32, 2.75, p<0.001) but not single-vessel disease (HR 1.15, 95%CI; 0.75, 1.77, p=0.516), compared to no obstructive CAD. There was no interaction between MVD and HFpEF or HFrEF status for the outcome of CV death (p=0.690). CV readmission was also significantly higher only in MVD (HR 1.28, 95%CI; 1.07, 1.54, p=0.008). Conclusion: In patients presenting with acute HF, angiographic MVD is associated with an increased rate of CV death and readmissions over 2 years.

Clinical Outcomes After Current-Generation Drug-Eluting Stent Implantation for Ostial Left Circumflex Lesions

BackgroundThere are no available data about clinical outcomes of simple stenting for ostial left circumflex (LCX) lesions using current generation drug-eluting stents (cDES). ObjectiveWe assessed clinical outcomes after simple stenting using cDES for ostial LCX lesions. MethodsWe identified 81 consecutive patients who underwent PCI using cDES for ostial LCX lesions at New Tokyo Hospital, Matsudo, Japan between January 2010 and December 2016. An ostial LCX lesion was defined as a lesion with more than 75% stenosis by visual assessment and within 3 mm of the left main (LM) stem. The primary endpoint was target lesion failure (TLF). TLF was defined as a composite of cardiac death, target lesion revascularization (TLR) and myocardial infarction (MI). Additionally, we also assessed the revascularization for LM to left anterior descending artery (LAD) after ostial LCX stenting. ResultsThe TLF rate at 3 years after PCI was 24.5%. Furthermore, the rate of TLR and revascularization for LM-LAD after ostial LCX stenting were significantly higher in patients who were previously undergone stent implantation in ostial segment of LAD. ConclusionClinical outcomes after cDES implantation for ostial LCX lesion could be acceptable. However, it could have better to be avoided in patients who previously received stent implantation in ostial segment of LAD.

Myocardial perfusion imaging in patients with unprotected left main disease.

The management of patients with unprotected left main (LM) coronary artery disease remains challenging, with recent data casting a shadow of doubt on the safety of percutaneous coronary intervention. We aimed at describing the features of patients undergoing myocardial perfusion imaging (MPI) subsequently found to have LM disease. We queried our institutional database for subjects without prior revascularization or myocardial infarction (MI), who had undergone MPI followed by invasive coronary angiography within 6 months, comparing those with evidence of angiographically significant LM disease (i.e. diameter stenosis ≥50%) to those without significant coronary artery disease (CAD), or those with CAD not involving LM. Baseline, stress and imaging features were systematically collected and analyzed, and clinical outcomes (death, myocardial infarction, revascularization) sought. We included a total of 74 patients with LM disease, which were compared with 70 without CAD, and 920 with significant CAD not involving LM. MPI was remarkably safe in all subjects, and significant differences were found for several features, but particularly so for ST change, rate pressure product, and left ventricular ejection fraction (all P<0.05). Most patients with LM disease had moderate or severe ischemia, and the apical, lateral and inferior regions were the most sensitive ones. Clinical outcomes after an average of 35 months were worse in patients with LM disease than in subjects with significant CAD not involving LM, albeit non-significantly, possibly in light of the higher use of coronary artery bypass grafting. MPI is safe and informative in patients with LM disease, and multidimensional appraisal of MPI results may guide decision-making on top of providing prognostic detail and warranty period.

Performance of Thin-Strut Stents in Non-Left Main Bifurcation Coronary Lesions: A RAIN Subanalysis.

This study assesses the safety and efficacy of thin-strut stents in non-left main (non-LM) bifurcation coronary lesions. Thinner struts of recent drug-eluting stent (DES) devices are associated with improved outcomes, but data about their performance in challenging scenarios are scant. RAIN was a retrospective multicenter registry enrolling patients with coronary bifurcation lesions or left main (LM) disease treated with thin-strut DESs. Target-lesion revascularization (TLR) was the primary endpoint, while major adverse clinical event (MACE) rate, a composite of all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), TLR, and stent thrombosis (ST), and its single components were the secondary endpoints. Multivariable analysis was performed to identify predictors of TLR. Outcome incidences according to stenting strategy (provisional vs 2-stent technique), use of final kissing balloon (FKB), and intravascular ultrasound/optical coherence tomography optimization were further investigated in prespecified subanalyses. A total of 1803 patients (59% acute coronary syndrome, 41% stable coronary artery disease) with non-LM bifurcations were enrolled. After a median follow-up of 12 months, TLR incidence was 2.5% (2.2% for provisional stenting and 3.5% for 2-stent technique). MACE rate was 9.4% (all-cause death, 4.1%; MI, 3.2%; TVR, 3.7%; definite ST, 1.1%). After multivariable adjustment, postdilation (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.15-0.71; P<.01) and provisional stenting (HR, 0.62; 95% CI, 0.55-0.89; P=.03) were associated with lower TLR rates. FKB was associated with a lower incidence of TLR in the 2-stent subgroup (P=.03). Intracoronary imaging had no significant impact on the primary endpoint. Thin-strut DES options represent an effective choice in bifurcation lesions. Postdilation and provisional stenting are associated with a reduced risk of TLR. FKB should be recommended in 2-stent techniques.

Prevalence and Impact of High Bleeding Risk in Patients Undergoing Left Main Artery Disease PCI.

The aim of this study was to determine the prevalence and prognostic impact of high bleeding risk (HBR), as determined by the Academic Research Consortium HBR criteria, in real-world patients undergoing left main (LM) percutaneous coronary intervention (PCI). LM PCI is often reserved for patients at increased risk for periprocedural adverse events. Patients at HBR represent a relevant percentage of this cohort, but their outcomes after LM PCI are still poorly investigated. All patients undergoing LM PCI between 2014 and 2017 at a tertiary care center were prospectively enrolled. Patients were defined as having HBR if they met at least 1 major or 2minor Academic Research Consortium HBR criteria. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 12months. Among 619 enrolled patients, 55.3% were at HBR. The rate of the primary endpoint was 4-fold higher in patients at HBR compared with those without HBR (20.5% vs 4.9%; HR: 4.43; 95% CI: 2.31-8.48), driven by an increased risk for all-cause death (HR: 3.88; 95%CI: 1.88-8.02) and MI (HR: 6.18; 95%CI: 1.83-20.9). Rates of target vessel or lesion revascularization and stent thrombosis were comparable in the 2 groups. Bleeding occurred more frequently in patients at HBR (HR: 3.77; 95%CI: 1.83-7.76). Consistent findings were observed after Cox multivariable regression adjustment. Among patients undergoing LM PCI, those with HBR are at increased risk for all-cause death, MI, and bleeding. Conversely, rates of repeat revascularization and stent thrombosis were comparable, suggesting frailty and comorbidities as primary causes of worse outcomes in patients at HBR.

Comparison of 2-Stenting Strategies Depending on Sequence or Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era - Analysis From the COBIS (Coronary Bifurcation Stenting) III Registry.

It has not been determined which specific 2-stenting strategy is the best for bifurcation lesions. Our aim was to investigate the clinical outcomes of various 2-stenting strategies in the era of 2nd-generation drug-eluting stents (2G-DES). We analyzed 454 patients who finally underwent 2-stenting for a bifurcation lesion, from among 2,648 patients enrolled in the COBIS III registry. The primary outcome was target lesion failure (TLF). Patients were analyzed according to stenting sequence (provisional [main vessel stenting first] vs. systemic [side branch stenting first]) and stenting technique (crush vs. T vs. culotte vs. kissing/V stenting). Overall, 4.4 years' TLF after 2-stenting treatment for bifurcation lesion was excellent: TLF 11.2% and stent thrombosis 1.3%. There was no difference in TLF according to 2-stenting strategy (11.1% vs. 10.5%, P=0.990 for provisional and systemic sequence; 8.6% vs. 14.4% vs. 12.9% vs. 12.2%, P=0.326 for crush, T, culotte, kissing/V technique, respectively). Only left main (LM) disease and a shorter duration of dual antiplatelet therapy (DAPT) were associated with TLF. The distribution of DAPT duration differed between patients with and without TLF, and the time-point of intersection was 2.5 years. Also, the side branch was the most common site of restenosis. The stenting sequence or technique did not affect clinical outcomes, but LM disease and shorter DAPT were associated with TLF, in patients with bifurcation lesions undergoing 2-stenting with 2G-DES.

Single stenting versus double stenting technique in true bifurcation coronary lesions

Abstract Introduction The ideal treatment technique for coronary bifurcation lesions remains unknown. Although single-stenting strategy has been recommended by default, little evidence exists regarding clinical outcomes between single versus double-stenting in current practice. Purpose To compare procedural details and clinical outcomes between single vs double-stenting techniques in true bifurcation coronary lesions. Methods Retrospective study of all patients (pts) referred for percutaneous coronary intervention (PCI) of true bifurcation lesions between June 2018 and June 2020. Only Medina X,X,1 lesions were included. Pts were split in 2 groups: group 1 (single-stenting) and group 2 (double-stenting). Procedural details and clinical outcomes were assessed. Acute and long-term adverse events included procedural complications (a composite outcome of side branch occlusion, coronary iatrogenic dissection and type 4 acute myocardial infarction (AMI)) and a composite of cardiovascular death, AMI, stroke, re-restenosis and reintervention, respectively. Results A total of 118 pts were included, 74,6% male, mean age of 66,4±11 years. Ninety-five pts (80,5%) were treated with single-stenting (G1) and 23 pts (19,5%) with double-stenting technique (G2). Both groups were well matched regarding baseline characteristics and clinical presentation. T and protrusion (TAP) and minicrush were the most frequent double-stenting techniques (43,5% and 21,7%). G2 lesions mainly involved the left main (LM) and proximal left anterior descendent artery (LAD) (52,2%) and in G1 mid LAD (34,7%). LM lesions were more common in G2 (26,1% vs 8,4%; p=0,030). G1 had more lesions Medina 1,1,1 (75,8% vs 52,2%; p=0,025) and less Medina 0,1,1 (9,5% vs 30,4%; p=0,015). Proximal optimization technique and kissing balloon occurred more in G2 (p&amp;lt;0,05). G2 had more intravascular ultrasound guided PCI (p=0,046). Femoral access, heparin, contrast and radiation dose, and fluoroscopy time were higher in G2 (p&amp;lt;0,05). Acute adverse composite outcome was similar in both groups (G1 13% vs G2 14,3%; p=0,855). Median follow-up was similar (G1 16,8±7,9 and G2 19,7±8,8 months; p=0,127). G1 had less occurrence of long-term adverse composite outcome (7,4% vs 26,3%; p=0,032). Excluding interventions in LM, G2 had more significant incidence of acute events (20% vs 2,6%; p=0,028), and higher rate of long-term adverse events (20% vs 4,2%; p=0,056). In interventions of the LM only, no differences were noticed in acute and long-term composite events between groups. Conclusions Double-stenting techniques in true coronary bifurcation lesions included more often LM lesions and were complex procedures requiring frequently intracoronary imaging. Although acute adverse events were similar to those of single-stenting, long-term adverse outcomes were more frequent in double-stent group, except for LM lesions. Funding Acknowledgement Type of funding sources: None.

Feasibility, safety and long term outcomes of complex left main bifurcation treatment using the nano inverted t stenting: a multicentre registry

Abstract Background The role of double stenting techniques in distal bifurcation left main (LM) disease has gaining interest over the latest years. Purpose We present the 3-year multicentre registry outcomes of dual stenting using ultra-thin strut stents and the Nano Inverted-T (NIT) technique in complex unprotected true LM bifurcation disease. Methods We analysed the procedural and medical data of consecutive patients enrolled between 1st January 2014 and 1st December 2019 in a multicentre registry for complex LM bifurcation disease treated with the double stenting technique called NIT due contraindications and/or refusal to surgical treatment. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel MI (TVMI) and clinically driven target lesion revascularization (TLR). Results Among two hundred-ninety-five patients (138 males, mean age 70.3±12.8 years), post-operative success was achieved in 100% of cases. Contrast volume, procedural time, and radiation exposure were 139.2±23.4 ml, 15.3±4.9 min, and 1080±1034 cGy/m2 (Figure), respectively. At a mean follow-up of 39.5±0.6 months TLF rate was 6.1% (n=18) while TLR and cardiovascular mortality rates were 3.0 (n=9) and 2.6% (n=8), respectively. Clinically driven angiographic follow-up was available in 26.4% of patients at a mean time from the procedure of 7.5±0.4 months. Clinically restenosis rate was 3.3%. Conclusions Revascularization of complex LM bifurcation disease using the NIT double stenting technique resulted feasible and safe with a low incidence of TLF, excellent survival rate and no stent thrombosis. Figure 1.The NIT technique is based on the use of ultra-thin strut (≤80 micron) stents and double stenting starting with side branch stenting frst. The side branch stent is precisely positioned with one possibly only strut protruding into the main vessel which is balloon crushed before the implantation of the main branch stenting. The Proximal optimization technique (POT)–snuggle kissing–POT sequence is mandatory to ensure the coverage of the side branch ostium by both side branch and main branch stents. Snuggle kissing was performed placing the LCX balloon with the proximal marker at the middle rather than at the proximal marker of the LM-LAD balloon, in order to minimize the elliptical deformation of the LM stent. Funding Acknowledgement Type of funding sources: None. Figure 1

Location and impact of the infarct-related artery in acute coronary syndrome: insight from the Swiss SPUM- ACS cohort

Abstract Background Identifying the infarct-related artery (IRA) in patients with acute coronary syndromes (ACS) has prognostic and therapeutic implications. Purpose We aimed to evaluate the distribution, clinical presentation and impact of the culprit lesion location on long-term outcomes in ACS patients treated with primary percutaneous coronary intervention, medication and secondary prevention according to Guidelines. Methods Patients referred for ACS to one of the participating centres of the observational SPUM-ACS study between 2009 and 2017 with one year outcomes and independent events adjudication were included. The distribution of IRA, clinical presentation (STEMI/NSTEMI) and impact of IRA location on major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, target vessel revascularisation) at one year were investigated. Results 4'546 patients were included with 55% presenting as STEMI (mean age 62-years; 20% women), 42% as NSTEMI and 3% as unstable angina. The left anterior descending (LAD) artery was involved in 44.3%, the right coronary artery (RCA) and left circumflex artery (LCX) in 32.9% and 20%, respectively. Proximal and middle segments of the 3 main vessels were more often the culprit location compared to distal segments and side branches (78% versus. 22%). Left main (LM) and bypass graft were rarely involved (1.6% and 1.2% respectively), but most often responsible to overall cardiac dysfunction (higher NT-proBNP and hs troponin levels). Patients with an occluded IRA at angiography usually presented as STEMI on ECG (100% for LM, 90.5% for LAD territory, 83.8% for RCA territory, 56.6% for LCX territory). However 43.1% of patients with occluded LCX presented as NSTEMI. These patients were prone to extensive cardiac damage and significantly higher hs troponin levels as compared to those with patent LCX or STEMI presentation (626 ng/l vs 310 ng/l and 626 ng/l vs 580 ng/l respectively, p&amp;lt;0.001). Overall, 1-year MACE occurred in 11.8%. In native coronaries, the location of IRA had no impact on outcomes (20% LM, 10.9% LAD, 11.8% RCA, 11.8% LCX, p=0.112). However, in NSTEMI-ACS there were twice as many events when the LM was the IRA (MACE 20%, p=0.023) and 3-times higher when a bypass-graft was the IRA (33.9%, p=0.0001). Conclusions ST elevations are highly suggestive of an occluded IRA. However more than 40% of patients presenting with ACS involving an occluded LCX did not demonstrate ST-elevation and were prone to extensive cardiac damage, urging the necessity for early invasive measures in these patients. In native coronaries the IRA location did not affect outcomes except in NSTEMI with LM involvement or ACS with bypass grafts as IRA that had much worse outcomes. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): - Swiss National Research Foundation - Zurich Heart House

Mid-term mortality after stenting of distal left main stenosis with regular, third generation drug eluting stent or dedicated bifurcation stent or surgery-registry based,all-comers data

Abstract Background Distal left main (LM) bifurcation lesions remain a challenge for interventional cardiologists and they are associated with significant morbidity and mortality. The aim of the current study was to identify predictors of cardiac mortality at mid-term follow up after PCI (DES vs. dedicated bifurcation stent) or CABG. Methods All patients with distal LM stenosis ≥50% were included in prospective registry starting from 01.2015. The exclusion criteria for registry are cardiogenic shock, a priory life expectancy duration &amp;lt;1 year, lack of inform consent. All patients were prospectively followed about the alive status through the national security number data base. All deaths were deemed cardiac if proof otherwise (the data patient families or family's physicians were contacted through phone call about the reason of death) Results For three year follow up period (median 35 months, IQR 18–50) 303 patients were included. 220 patients were stented with 3rd generation DES, 43 with dedicated bifurcation stent BiOSS (Balton, Poland), and rest were sent for CABG. The mean age was 67±10 years, 72% were males, 37% diabetics, all with hypertension, 97% dyslipidemia, 15% PAD, 9% COPD, 16% carotid artery disease, previous MI 28%, previous PCI 50% - without significant difference between three groups. The frequency of acute coronary syndrome during admission was 11% - without difference in frequency between groups. The patient referred to CABG had significantly lower left ventricular EDV and ESV, more severe mitral regurgitation and kinetic disturbances, higher SYNTAX score and longer lesion length. On univariate COX regression analysis, the following factors were associated with mortality: age, NYHA class, GFR, baseline troponin, hemoglobin, LV EF, mitral regurgitation, kinetics disturbances, treatment with beta blockers, ACE inhibitors, statin, atrial fibrillation, SYNTAX score, lesion length. The type of treatment was not associated with differences in mortality (figure). On COX multiple regression survival analysis independent predictors of survival were: age (HR=1.036, CI 1.005–1.068, p=0.023); COPD (HR=2.313, CI 1.170–4.572, p=0.016); GFR (HR=0.988, CI 0.978–1.000, p=0.048); hemoglobin (HR=0.970, CI 0.955–0.986, p=0.000); left ventricular EF (HR=0.958, CI 0.832–0.985, p=0.003). Conclusions The type of treatment was not associated with mid-term mortality. Our data demonstrate that dedicated bifurcation stent could be used safely for distal LM stenosis treatment with similar safety as 3rd generation DES. Funding Acknowledgement Type of funding sources: None.

Stent strategies in left main bifurcation lesions: the simpler, the better?

Abstract Introduction Although percutaneous coronary intervention (PCI) for ostial or midshaft lesions in left main (LM) disease has shown similar results as compared with coronary artery bypass grafting (CABG), distal LM bifurcations are associated with an increase in procedural complexity and higher rates of target lesion revascularization. Several studies have investigated the optimal stenting strategy in patients with coronary bifurcation lesions and showed no benefit for systematic two-stent approach in comparison with provisional stenting. This is reflected in the current guidelines that recommend provisional stenting of the side branch as the preferred approach for most bifurcation lesions. However, there is still debate about the optimal strategy according to lesion location. Objectives This analysis aimed to compare the clinical outcomes of LM bifurcation PCI using a provisional strategy versus a two-stent strategy. Methods Retrospective, observational study including patients submitted to LM bifurcation (Medina 1,1,1) PCI between January 2010 and December 2019. Data was collected from the emergency department and hospitalization registries. Patients were divided according to the stenting approach. We made a global analysis including baseline clinical and angiographic data. The primary endpoint was target lesion failure (TLF), defined as the composite of myocardial infarction, cardiac death, and target lesion revascularization (TLR). Secondary endpoints included the individual components. Results A total of 106 patients were included (median age 74 [66–82], 79 (74.5%) males), 57 (53.8%) submitted to provisional stenting and 49 (46.2%) to a two-stent technique. Baseline characteristics were well matched (table 1). The mean SYNTAX score was 29.6±10.0 and LM stenosis grade was ≥70% in all lesions. Median follow-up was 26.6 [12.0–48.6] months. No differences were found regarding the primary endpoint (TLF in provisional stenting was 21.7% vs 21.4%, HR 2.432; 95% confidence interval, 0.472–12.450; p=0.233.). Although target lesion revascularization within the LM complex was numerically higher in the two-stent group (10.2% vs. 3.5%, p=0.245), the opposite was found in cardiac death (provisional group 10.5% vs. 4.3%, p=0.289). Conclusions Besides being a “simpler” technique, provisional stenting had no significant differences in outcomes compared to two-stent techniques. Without further evidence, revascularization strategies should primarily rely on operator expertise. Funding Acknowledgement Type of funding sources: None.

Coronary artery cavitation as a trigger for atherosclerotic plaque progression: a numerical and computational fluid dynamic demonstration

Abstract Background Coronary cavitation is supposed to be generated by both concentric and eccentric coronary artery stenosis creating microbubbles which exploded when the fluid pressure was lower than the vapor pressure at a local thermodynamic state. Aims To assess, using computational fluid dynamic analysis (CFD), the potential role of cavitation in inducing coronary artery endothelial damage and promote atherosclerotic plaque progression. Methods We retrospectively reviewed the procedural records of consecutive patients evaluated between 1st January 2013 and 1st January 2014 with an isolated hemodynamically significant Left Main (LM) disease. Each bifurcation was reconstructed on the patient-specific geometries derived from the CCTA applying patient-specific hemodynamic features. Vapour has been modelled as discrete vapour bubbles and its trajectory determined using a Lagrangian frame of reference. Cavitation started with micro-cavitation nuclei which subsequently grow into bubbles undergoing different physical processes determined in a stochastic Monte-Carlo approximation. Results Among the 12 patients analysed [8 males, mean age 68.2±12.8 years old], the mean LM stenosis was 72.3±3.6%. In all subjects, LM stenoses induced cavitation which propagates downstream the vessel. The higher concentration of vapour region was detected before the carina (within 0.8 to 1.3 cm from the stenosis). The mean bubbles radius observed before the carina was 4.2±1.4 μm; their impact with the endothelial surface generated a mean peak pressure of 3.9±0.5 MPa determining a local shockwave (Figure 1). Conclusion The collapse of micro-bubbles alongside the endothelium generated micro-shockwaves determining repeated dynamic load measurable as an instantaneous pressure-peaks able to induce endothelial injury or dysfunction. Funding Acknowledgement Type of funding sources: None. Figure 1. (A) The simulation illustrates the vapour fraction iso-surfaces and the scattered bubble plots as predicted by the Langrangian model. Notably, most cavitation bubbles that form at the inlet of left main bifurcation do not collapse immediately but they are transported towards the vessel determining several interactions with the endothelium. (B) Graphical representation of the bubble radius modification and related pressure transmitted to the endothelium if the bubble collapse happened near to this last one. The magnification in boxes (B1-B4) evidences the dynamic modification of bubbles. The re-entry jet causing the collapse is evidenced with a red arrow.

AMI causing cardiogenic shock in patients with severely depressed left ventricular function

Abstract Introduction Left ventricular function is assumed to be the main predictor of cardiogenic shock (CS), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction. Purpose Characterize population of patients (Pts) with CS after acute myocardial infarction (AMI) and with severe left ventricular dysfunction (defined as ejection fraction (EF) &amp;lt;30%). Methods From a national multicenter registry, we evaluated 729ptswith CS after AMI.We considered 2 groups: Group 1 – pts with CS and EF &amp;lt;30% and Group 2 – pts with CS and EF &amp;gt;30%. We registered age, gender, cardiovascular and non-cardiovascular comorbidities, electrocardiographic presentation, vital signs at admission, reperfusion strategy and coronary anatomy. We also evaluated in-hospital complications, such as re-infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT), atrial fibrillation (AF) and stroke. We compared in-hospital mortality and multivariate analysis was performed to assess the impact of EF in in-hospital mortality and to identify predictors of severe left ventricular function. Results Severe dysfunction in Cardiogenic shock due to AMI was present in 28.9% (n=211) of pts (68% male, mean age of 72±12 years old). Group 1 had higher incidence of previous heart disease, such as AMI, previous PCI and congestive heart failure (27% vs 14%, p&amp;lt;0.001; 17.7% vs 9.6% p=0.002 and 16% vs 10%, p=0.022, respectively). STEMI pts were 71% (n=149), and timing from symptoms until first contact was longer (185 min (90; 437) vs 123 (60; 300), p&amp;lt;0.001). Undetermined location AMI was more often in group 1 (8% vs 2%, p&amp;lt;0.001), particularly due to left or right bundle brunch block (13% vs 4.7%, p&amp;lt;0.001, and 15% vs 10%, p=0.041 respectively). Anterior STEMI was also more prevalent in this groups (81% vs 46%, p&amp;lt;0.001). No differences were observed on coronariography rate, rate or type of reperfusion nor multivessel disease. Group 1 pts presented more with left main (LM) (25% vs 12%, p&amp;lt;0.001) and anterior descending (AD) (9.4% vs 2.4%, p&amp;lt;0.001) arteries lesions (88% vs 72.4%, p&amp;lt;0.001) or occlusion (65.5% vs 33.7%, p&amp;lt;0.001). Group 1 presented more with in-hospital VT (16% vs 10.8%, p=0.048). In-hospital mortality was also higher (56.5% vs 29.5%, p&amp;lt;0.001). After multivariate analysis we found that severe left ventricular dysfunction was a mortality predictor (OR 3.37; 95% CI 2.05–5.54, p&amp;lt;0.001). LM (OR 3.41; 95% CI 1.86–6.26, p&amp;lt;0.001) and AD (OR 2.74; 95% CI 1.51–4.96, p=0.001) arteries disease and previous AMI (OR 2.36; 95% CI 1.28–4.37, p=0.006) were predictors of severe LV dysfunction. Conclusions Severely depressed EF is a predictor of in-hospital mortality. Left main and anterior descending artery disease and previous AMI were identified as predictors of an EF &amp;lt;30%. Funding Acknowledgement Type of funding sources: None.

Drug-eluting balloon catheters in the treatment of left main coronary artery bifurcation lesions: 4-years follow-up

Abstract Aim To evaluate the long-term results of the use of drug-eluting balloon catheters in patients with Left Main (LM) bifurcation stenosis. Methods The analysis involved 142 patients with true bifurcations of the Left Main. Randomization in 2 main groups: Group I (n=52) included patients, who received kissing- dilatation with traditional NC balloon catheters and Group II (n=52), who had a kissing-dilatation of the main bifurcation artery with a traditional NC balloon catheters, and a side branch - with drug-eluting balloon catheters. In retrospectively, the third (III) control group (n=38) was formed, where the two-stent technique was performed. All patients from main groups had previously performed “Provisional T” stenting and final “kissing balloons” dilation technique. Coronary angiography and OCT were performed to evaluate the results of all patients. Inclusion criteria: true LM bifurcation stenoses according to QCA and OCT; SYNTAX score &amp;lt;32. Primary endpoints: incidence of MACE - death, MI, re-interventions. Secondary endpoints: the incidence of restenosis and late stent thrombosis. Results The long-term results after 4-years were observe in 46 patients from Group I and 48 patients from Group II. Restenosis of the side branch of more than 50% according to QCA was detected in 12 patients (26.0%) from Group I and in 5 patients (10.4%) from Group II (p&amp;lt;0.05). In-stent restenosis of the main vessel of more than 50% according to QCA was detected in 4 patients (8.6%) from Group I and in 1 patients (2.1%) from Group II (p&amp;lt;0.05). In patients from group I, the average MLA in the side branch after 4-years compared with data after PCI was 5.58±1.34 and 4.12±1.21 mm2, respectively (p&amp;lt;0.05), in the main branch – 6.34±1.56 and 5.88±1.14 mm2, respectively (p&amp;gt;0.05). In patients from Group II, the average MLA were, respectively, 5.38±1.24 and 5.01±1.14 mm2 in side branch (p&amp;gt;0.05) and 6.68±1.75 and 6.36±1.22 mm2 in main branch (p&amp;gt;0.05). When comparing the data of MLA in the side branch in groups I and II, there was a significant difference (4.12±1.21 vs. 5.01±1.14 mm2; p&amp;lt;0.05).The repeat revascularization, in connection with the detected ischemia was performed in 7 patients (15.2%) from Group I and in 1 patients (2.1%) from Group II (p&amp;lt;0.05). In the Group I was observed non-fatal myocardial infarction in 2 patients (4.3%). The total incidence of MACE were 19.5 vs. 2.1% in groups I and II respectively (χ2=7.321; p&amp;lt;0.001). The survival without MACE was 97.9 and 80.5%, respectively (p=0.0219). Conclusions The use of dug-eluting balloon catheters for the “Provisional T” stenting in patients with true LM bifurcation stenosis, associated with good prognosis and demonstrated significantly lower frequency of MACE and side branch restenosis, according to OCT data, compared with patients who used traditional NC balloon catheters for “kissing-dilatation” and two-stent technique strategy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100

Optical coherence tomography, intravascular ultrasound or angiography guidance for distal left main coronary stenting. The ROCK cohort II study.

to test the safety and efficacy of intravascular imaging and specifically optical coherence tomography (OCT) as a diagnostic tool for left main angioplasty and analyze the mid-term outcome accordingly. Clinical data and international guidelines recommend the use of intravascular imaging ultrasound (IVUS) to guide left main (LM) angioplasty. Despite early experience using OCT in this setting is encouraging, the evidence supporting its use is still limited. ROCK II is a multicenter, investigator-driven, retrospective European study to compare the performance of IVUS and OCT versus angiography in patients undergoing distal-LM stenting. The primary study endpoint was target-lesion failure (TLF) including cardiac death, target-vessel myocardial infarction and target-lesion revascularization. We designed this study hypothesizing the superiority of intravascular imaging over angiographic guidance alone, and the non-inferiority of OCT versus IVUS. A total of 730 patients, 377 with intravascular-imaging guidance (162 OCT, 215 IVUS) and 353 with angiographic guidance, were analyzed. The one-year rate of TLF was 21.2% with angiography and 12.7% with intravascular-imaging (p =0.039), with no difference between OCT and IVUS (p =0.26). Intravascular-imaging was predictor of freedom from TLF (HR 0.46; 95% CI 0.23-0.93: p =0.03). Propensity-score matching identified three groups of 100 patients each with no significant differences in baseline characteristics. The one-year rate of TLF was 16% in the angiographic, 7% in the OCT and 6% in the IVUS group, respectively (p =0.03 for IVUS or OCT vs. angiography). No between-group significant differences in the rate of individual components of TLF were found. Intravascular imaging was superior to angiography for distal LM stenting, with no difference between OCT and IVUS.

Manifestation of Acute Coronary Syndrome in Critically Aortic Stenosis Patients

The clinical presentation of acute coronary syndromes (ACS) is broad, from cardiac arrest, electrical or haemodynamic instability with cardiogenic shock (CS) due to ongoing ischaemia or mechanical complications such as severe mitral regurgitation, to patients who are already pain free again at the time of presentation. Critical aortic stenosis (AS) can cause inadequate myocardial perfusion and in the absence of demonstrable coronary stenosis or occlusion which resulting in ACS manifestation. Critical AS (defined as valve area &lt;0.5 cm2) has been reported to cause mild increases in cardiac biomarkers such as troponin I. A 56-year-old man was admitted to hospital with chief complaint of typcal chest pain. Electrocardiogram (ECG) shows myocardial infarction in left main (LM) equivalent. Echocardiography revealed critical aortic stenosis. Cardiac marker also shows increasing. However, diagnostic coronary angiography (DCA) did not identify any lesions to account for the patient’s electrocardiographic changes and ongoing symptoms of chest pain. Consultation to cardiothorax surgeon to have urgent aortic valve replacement (AVR) were planned and underwent successful aortic valve (AV) replacement without coronary intervention. The definitive treatment for symptomatic severe AS is AVR. Some of the treatments that can be done are immediate coronary angiography and reperfusion procedure if there is suspicion of coronary artery occlusion or stenosis which may cause myocardial infarction; Intra-Aortic Ballon Pump (IABP) if there are signs of myocardial injury with take caution to the contraindications of IABP placement; Perform intervention procedure as soon as possible on aortic valve; Administration of medical therapy for heart failure in symptomatic severe AS patients. The case emphasizes the importance of initial physical examination, ECG, echocardiography, and cardiac markers as a whole that we do in aortic valve stenosis patient presenting with ACS.

Short and long-term outcomes of patients with coronary artery bypass surgery

BACKGROUNDCoronary artery disease (CAD) is a major problem in Iran as well as throughout the globe, and coronary artery bypass grafting (CABG) surgery is an appropriate option for many patients with symptomatic and severe CAD. The main purpose of this study was assessment of the short and long-term outcomes of patients undergoing CABG in Yazd Province, Iran.METHODSThis historical cohort study examined the mortality rates of patients who had undergone CABG in Afshar Hospital in Yazd from 2011 to 2013. During this period, 2510 patients undergoing CABG were entered into the study and then followed for in-hospital and long-term mortality.RESULTSMean age of the patients was 61.37 ± 10.50 years and 34.1% were women. In-hospital mortality turned out to be 3.7% and age over 70, left ventricular (LV) dysfunction, female gender, and left main (LM) involvement induced significant higher in-hospital mortality. Of all the patients, 84.1% were followed for a period of 41 ± 20 months. The survival rate proved to be 92.4% in one year and 82.9% in five years. The patients with age over 70, diabetes mellitus (DM), and LV systolic dysfunction (LVSD) showed significant lower survival rate, whereas the patients with utilization of left internal mammary artery (LIMA) demonstrated significant higher survival rate.CONCLUSIONIn-hospital and long-term mortality rate of patients undergoing CABG surgery is acceptable in comparison with other studies and more effort is needed into making this event a success.

Clinical Outcomes and Prevalence of Intravascular Ultrasound Use at a Tertiary Care Hospital in a South Asian Country.

Objectives:Intravascular ultrasound (IVUS) plays a pivotal role in the current era of coronary interventions. We aimed to determine the prevalence of IVUS use and clinical outcomes of IVUS-guided percutaneous treatment of coronary arteries lesions in a South Asian country.Material and Methods:It is a retrospective observational study, a total of 134 consecutive patients having done IVUS, was enrolled from January 2013 to March 2020 at a single center.Results:Out of 134 patients, 97 (72.4%) were male with a mean age of 63.1 ± 12.9 years. The prevalence of IVUS in our center was 3.0%. The most frequent comorbidity observed was dyslipidemia, n = 111 (82.8%). Non-ST-elevation myocardial infarction, n = 50 (37.3%), was the common mode of presentation. On coronary angiogram, the left main (LM) disease was found in n = 46 (34.3%), however, single-vessel disease, n = 51 (38.1%), was most commonly noted. IVUS utilization was higher in the left anterior descending, n = 94 (70.1%), followed by LM, n = 46 (34.3%). The LM mean minimal luminal area was 6.0 ± 2.6 mm2 and minimal luminal diameter was 4.53 mm ± 0.6 (mean). The coronary artery dissection was noted in n = 15 (11.2%). The mean duration of follow-up in our study was 40.3 ± 30.1 months. Major adverse cardiac events (MACEs) were recorded in n = 13 (9.7%), which included heart failure, n = 4 (3%). Cardiovascular death and target vessel revascularization occurred in n = 3 (2.2%).Conclusion:IVUS results in a significant decrease in MACE. Our data might support the broader use of IVUS in both developed and in our part of the world.