Left Main Research Articles

Predictor of left main coronary artery size: an intravascular ultrasound study in Southeast Asia population.

Left main (LM) percutaneous coronary intervention (PCI) has expanded rapidly in the past decade, with up to fourfold increase annually. Recent trials found that intravascular imaging (IVI)-guided LM PCI resulted in lower risks of cardiac death and stent failure due to suboptimal PCI compared to angiography-guided PCI. IVI usage has increased in recent years; however, its utilization remains variable across regions and is still incredibly low in developing countries. Furthermore, to date, there is no data about LM size in the Southeast Asian population. This study aims to determine the mean external elastic membrane (EEM) diameter, cross-sectional area (CSA) of LM, and its predictor. This is a cross-sectional observational study on 100 patients with coronary artery disease (CAD) who underwent IVUS-guided PCI with a pullback to LM in Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from January 2020 until December 2022. Linear regression was used to determine the predictors of LM size. There were 100 segments of LM. LM's mean EEM diameter and CSA were 5.02 ± 0.43mm and 19.93 ± 3.48mm2. Body surface area (BSA) is an independent predictor of EEM diameter and CSA with a positive linear relationship (p 0.001 and p 0.0001). Hypertension is an independent predictor of EEM diameter with a positive linear relationship (p 0.034). The linear equation to predict EEM diameter and CSA were (2.741 + 1.272BSA(m2) + 0.165 hypertension (yes)) and (2.745 + 9.601BSA(m2)), respectively. The LM coronary artery size of the Southeast Asian population was comparable with the previous studies. BSA and hypertension are independent predictors of EEM diameter, with BSA being stronger than hypertension. Neither sex nor other cardiovascular risk factors affect the LM size. The knowledge of coronary artery size will help the clinician have a reference for intervention, especially when no intravascular imaging is available.

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes

IntroductionCulotte stenting is an effective strategy for left main coronary bifurcation lesions. Increased side branch ostial restenosis is the main drawback of Culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al. has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. AimWe report immediate and short-term results of Double Kissing (DK) mini-Culotte stenting with a one-year angiographic follow-up. MethodsForty-five patients of distal left main (LM) disease underwent DK mini-Culotte stenting at our center between March 2020 and December 2022 under Optical Coherence Tomography (OCT) guidance. ResultsOut of 45 patients [male:35(77.77%); mean age:63.67±4.94years], chronic coronary syndrome was present in 26(57.8%) and unstable angina in rest. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1) with a median Syntax score of 28 (IQR=23-29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under OCT guidance, adequate minimal stent area (MSA) of 13.28 ± 0.77mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45mm2 was achieved in LM, left anterior descending (LAD) and left circumflex (LCx) respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events (MACE) was 2.2%. Further, one (2.2%) patient developed restenosis of the side branch which was managed conservatively. ConclusionDK mini-Culotte stenting in the distal left main bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

Coronary artery size based on intravascular ultrasound in Southeast Asia population

BackgroundOne of the downsides of percutaneous coronary intervention (PCI) is stent failure which could be related to stent underexpansion. Hence, PCI based on an accurate coronary artery size obtained from intracoronary imaging is tremendously important. Until now, there is no data about all coronary artery dimensions in the Southeast Asian population performed by intravascular ultrasound (IVUS). The coronary artery size of 153 patients with chronic coronary syndrome (CCS) in acute or chronic settings who underwent percutaneous coronary intervention (PCI) with IVUS was examined. The mean artery size and its predictors were analyzed.ResultsThere were 153 patients with 633 coronary artery segments: the mean left main (LM) external elastic membrane (EEM) diameter and cross-sectional area (CSA) were 5.02 ± 0.43 mm and 19.93 ± 3.48 mm2, proximal left anterior descending artery (LAD) 4.25 ± 0.42 mm and 14.34 ± 2.85 mm2, the mid-LAD 3.86 ± 0.39 mm and 11.70 ± 2.24 mm2, the distal LAD 3.32 (2.83–4.30) mm and 8.77(6.23–14.99) mm2, the proximal left circumflex artery (LCX) 3.91 ± 0.42 mm and 12.07 ± 2.53 mm2, the distal LCX 3.51 ± 0.47 mm and 9.90 (5.09–14.20) mm2, the proximal right coronary artery (RCA) 4.50 ± 0.48 mm and 16.14 ± 3.43 mm2, the mid-RCA 4.16 ± 0.420 mm and 13.74 ± 2.72 mm2, the distal RCA 3.81 ± 0.41 mm and 11.59 ± 2.46 mm2, respectively. Body surface area (BSA) is an independent predictor for the majority of epicardial coronary arteries with a positive linear relationship.ConclusionsThe mean artery size of the Indonesian population was comparable with previous studies. The knowledge of coronary artery size will help the clinician to have a reference for intervention, especially when no intravascular imaging is available.

A 10-year Review of Left Main (LM) Coronary Artery Percutaneous Coronary Intervention (PCI) in South Western Sydney Local Health District (SWSLHD)

A 10-year Review of Left Main (LM) Coronary Artery Percutaneous Coronary Intervention (PCI) in South Western Sydney Local Health District (SWSLHD)

Pivotal Decision for Acute Coronary Syndrome Patient with Left Main Coronary Artery Disease, When to Choose PCI over CABG

Background: Surgery is acceptable as a standard treatment of Left Main Coronary Artery (LMCA) Disease in a stable angina condition. But, in Acute Coronary Syndrome (ACS) setting, LMCA intervention is a still clinical challenge in many cardiac centers. Percutaneous coronary intervention (PCI) has emerged as a suitable alternative to coronary artery bypass grafting (CABG) for high-risk complex coronary artery disease (CAD) scenario. This study aimed to outline the management of NSTEMI patient include LMCA disease. Case presentation: A 72-year-old male presented with persistent chest pain, with a confirmed NSTEMI. A coronary angiography was done and revealed Three Vessel Disease (TVD) and Left Main (LM) CAD with highly calcified stenosis in the distal LM and Left Anterior Descending (LAD). An early invasive procedure was successfully performed for severely calcified LAD artery and distal LM lesions, using proper selection of several bail-out pre-dilatation difficult attempts such as scoring ballon and rotational atherectomy (RA). We observed the aftercare period, which showed no subsequent ACS events. Conclusion: Managing ACS patients requires careful consideration and risk assessment before deciding on revascularization procedures, especially in high-risk case such as LMCA disease. PCI can be an effective treatment strategy for this population but require good consideration of patient’s anatomical factors, comorbidities, the availability of appropriate skill and equipment. Keyword: Acute Coronary Syndrome, Coronary Artery Bypass Graft Surgery, Left Main Coronary Artery, Percutaneous Coronary Intervention.

Cracking the Code of Coronary Calcium: One-year Clinical Outcomes of Intravascular Lithotripsy in All-comers and Two Complex Cohorts

Background: Severe coronary calcifications are commonly encountered in real-world populations and in left main (LM) disease, heightening complication risks including stent underexpansion. Although intravascular lithotripsy (IVL) appears safe, longer-term data in high-risk populations are lacking. The aim of this study was therefore to examine 1-year IVL outcomes for severely calcified lesions in two complex cohorts: LM stenosis and underexpanded stents (UES) during stent implantation. Methods: A registry study was carried out to examine major adverse cardiovascular events (MACEs) (MI, target vessel revascularisation [TVR], cardiac mortality). The LM and UES subgroups were compared with their counterparts in the non-LM and de novo lesion subgroups, respectively. Results: The study involved 102 participants (median age, 70 years, 68% male), and the cardiovascular burden was high (diabetes, 72%; dialysis, 18%; prior MI, 43%, median left ventricular ejection fraction, 45%). Many participants presented acutely (acute coronary syndrome, 36%; decompensated heart failure, 13%) and had complex anatomies (triple-vessel disease, 77%). The cardiovascular burden was higher in the LM and UES subgroups than in the non-LM and de novo lesion subgroups, but the rates of procedural complications and 30-day MACEs were low and were not significantly different. The 1-year MACE rate was higher in the LM group than in non-LM (29% versus 10%, p=0.042), but was non-significant after adjusting for baseline variables (OR 3.08; 95% CI [0.87–10.9]); the rates of 1-year MI, TVR and mortality did not differ from non-LM. In the UES group, 1-year MACE rate (17% versus 13%, p=0.500) was similar to that for de novo lesions. Conclusion: The preliminary data suggest that the use of IVL is reasonable when encountering stent underexpansion due to severe coronary calcifications during stent implantation. The 1-year MACE rate was higher in calcific LM stenosis, probably due to greater comorbidity burden and acute presentations.

Validation of the Cut-Plane Method for Accurate Measurement of Side-Branch Ostium Area in Coronary Bifurcation Lesions: A 3D-OCT Analysis.

This study aimed to validate the effectiveness, accuracy, and feasibility of the cut-plane method for measuring the side branch (SB) ostium area in three-dimensional optical coherence tomography (3D-OCT) pullbacks performed in the main branch (MB). A total of 109 sets of OCT pullbacks from the MB and SB of coronary artery bifurcation lesions were analyzed using Vivolight OCT software. Measurements of the SB ostium area from the MB and SB pullbacks were analyzed. Measurements of the SB ostium area from the actual SB pullback were used as a reference. 3D cut-plane analysis was used to estimate the correlations and mean errors with the reference measurements. Thirty-four sets of OCT images from the C7XR system and 75 sets from the CornarisTM system were analyzed using Vivolight software. There was a strong correlation between the reference measurements of the SB ostium area and the measurements obtained through 3D cut-plane analysis in the overall dataset (r = 0.925). This correlation was observed consistently with both the C7XR system (r = 0.955) and CornarisTM system (r = 0.900). Similar results were found in subset analyses of true and nontrue bifurcations (r = 0.936; r = 0.898, respectively) and in left main (LM) or non-LM bifurcation subsets (r = 0.932; r = 0.873, respectively). There were strong correlations between measurements of the SB ostium area by 3D-OCT and the reference measurements, and thus may be a reliable and accurate alternative to direct OCT pullback examinations of the SB.

Вплив результатів внутрішньосудинного дослідження на безпосередній результат стентування основного стовбура лівої коронарної артерії

The purpose of the study is to optimize the immediate results of stenting of the main trunk of the left coronary artery (LCA) in patients with coronary heart disease (CHD) using intravascular imaging methods and modern technological approaches.Materials and methods. We present the experience of 186 consecutive patients with coronary artery disease in whom stenting of the Left Main (LM) coronary artery was performed.Results. Patients were divided into 2 groups – group I, «historical» (100 patients), where the intervention was performed without the use of intravascular imaging methods and proximal optimization methods (POT), and group II, which consisted of 86 patients in whom LM stenting was performed using intravascular imaging and modern methods of optimizing the stented segment. In general, groups I and II were comparable. About 20 % of patients had an isolated LM lesion. In other cases, according to the results of coronary angiography, multivessel lesions of the coronary vessels were recorded in the patients. The localization of the lesion was defined as ostial in 7.5 %, stem – 6.9 %, and distal with the involvement of LAD&CX in 85.6 %. Stenting with 1 stent was used in 132 patients (71 % of cases).Analyzing the final size of the stented LM segment in the groups, we noticed, that in group I, this figure was 3.41±0.41 mm, while in group II it was 3.97±0.61 mm (p<0.0001). In 3 patients of group I in 30 day period cardiac death were recorded, in the group II there were 2 (2.3 %) cases of LM dissection treated with additional stent implantation.In 3 patients (3 %) group I sudden cardiac death was registered in the 30-day period. In group II, there were 2 (2.3 %) cases of ossification, which were resolved by additional stent implantation.Conclusions. Intravascular imaging to assess the size and results of the intervention, as well as the use of the POT technique, significantly improves the positioning of the stent in the artery and provides a significantly larger diameter of the stented LM. Adequate optimization of the size of the stented LM can be obtained only with the help of intravascular imaging methods.

Preprocedural assessment of coronary artery disease in patients undergoing transcatheter aortic valve implantation: Rationale and design of the EASE-IT CT registry.

Invasive coronary angiography (ICA) is the standard for pre-procedural assessment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI). However, it requires hospitalization and can be associated with complications. Computed tomography angiography (CTA) may be a viable alternative to rule out prognostically relevant CAD. The EASE-IT CT Registry is an investigator-initiated, prospective, observational, multicentre pilot registry involving patients aged ≥75 years with severe aortic stenosis (AS) intended to implant a transcatheter heart valve (THV) of the SAPIEN family. A total of 150 patients will be recruited from four sites in Germany and Austria. The registry will consist of two prospective cohorts: the investigational CTA-only cohort and the CTA + ICA control cohort. The CTA-only cohort will enrol 100 patients in whom significant (≥50%) left main (LM) and/or proximal left anterior descending artery (LAD) stenosis are ruled out on CTA. The CTA + ICA control cohort will enrol 50 patients who have undergone both CTA and ICA before TAVI and in whom ≥50% LM/proximal LAD stenosis has been ruled out by CTA. Three composite endpoints will be assessed at 3 months post-TAVI: CAD-specific endpoints, VARC-3-defined device success and early safety. The EASE-IT CT Registry evaluates whether TAVI can be carried out safely without performing ICA if prognostically relevant CAD of the LM/proximal LAD is ruled out with CTA. If so, the omission of ICA would help streamline the pre-procedural workup of TAVI patients.

Characterization and Management of Stable Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation

Background/Objectives: To date, data regarding the characteristics and management of obstructive, stable coronary artery disease (CAD) encountered in patients undergoing transcatheter aortic valve implantation (TAVI) are sparse. The aim of the study was to analyze granular details, treatment, and outcomes of patients undergoing TAVI with obstructive, stable CAD from real-world practice. Methods: REVASC-TAVI (Management of myocardial REVASCularization in patients undergoing Transcatheter Aortic Valve Implantation with coronary artery disease) is an investigator-initiated, multicenter registry, which collected data from patients undergoing TAVI with obstructive stable CAD found during the pre-TAVI work-up. Results: A total of 2025 patients from 30 centers worldwide with complete follow-up were included in the registry. Most patients had single-vessel CAD (56.1%). An involvement of proximal coronary tracts was detected in 62.5% of cases, with 12.0% of patients having CAD in left main (LM). Most patients received percutaneous coronary intervention (PCI) (n = 1617, 79.9%), especially those with proximal CAD (90.4%). At 2 years, the rates of all-cause death [Kaplan–Meier (KM) estimates 20.1% vs. 18.8%, plog-rank = 0.86] and of the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure (KM estimates 29.7% vs. 27.5%, plog-rank = 0.82) did not differ between patients undergoing PCI and those who were not. Conclusions: Patients undergoing TAVI with obstructive CAD more commonly had a single-vessel disease and an involvement of proximal coronary tracts. They were commonly treated with PCI, with similar outcomes compared to those treated conservatively.

Long-term outcome after unprotected left main percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock: a landmark analysis

Abstract Funding Acknowledgements None. Background Early revascularization of culprit arteries has demonstrated to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), however, little is known about long-term outcome after unprotected left main (LM) percutaneous coronary intervention (PCI) in patients with AMI-CS. Methods We retrospectively investigated 2325 consecutive patients with AMI who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death up to 3yrs. Results Among the 2325 eligible patients, 272 AMI patients (11.7%) were complicated by CS on admission (AMI-CS). The mean age was 71 years, 75% of patients were male, STEMI was seen in 86%, and mechanical circulatory support was used in 61%. Of 272 AMI-CS, 35 (14.0%) patients were treated with PCI for LM and had significantly higher 30-day cardiovascular mortality (52.6%) compared with those treated with PCI for non-LM (24.8%) (p = 0.0001). Kaplan-Meier analysis showed that mortality up to 3 years was significantly higher in AMI-CS patients with LM compared those with non-LM (p < 0.0001). Multivariate Cox regression analysis showed LM was significantly associated with higher cardiovascular mortality (adjusted HR 1.90, 95%CI 1.18-3.07, p = 0.0088). Conclusions Primary PCI of the LM was performed in 14.0% of patients with AMI-CS. Short- and long-term CV mortality was significantly higher with LM AMI-CS than non-LM AMI-CS. Further studies should evaluate to improve both short- and long-term outcome among AMI-CS with LM.

Abstract 2099: Coronary Artery Thrombosis Due To Intramural Hematoma

BJMC ,male 61 years old, presented with acute chest pain and non ST acute myocardial infarction. ECG showed ST segment depression on anterior and lateral precordial leads and ST elevation on aVR. Ultra-sensitive Troponin T rised . Coronary angiography showed calcified Left main(LM) with critical lesion extending to anterior descending artery. Percutaneous Coronary Intervention (PCI) was performed succesfully with stent implantation. Two hours later he started with epigastric discomfort , anxiety ,chest pain , diaphoresis , tachycardia and acute ECG changes , irresponsive to intravenous nitroglycerin . He evolved to ventricular tachycardia and cardiac arrest , with CPR. New PCI was followed with immediate clinical improvement . Clinical symptoms of ischemia and hemodynamic instability were due to significant (LM) caliber reduction .IMH is a pathological process were blood accumulate within the media space, suggesting new stenosis or spasm. IMH is unfrequent - may occur in initial hours and even at several days after apparently succesfull intervention. IMH causes acute lumen obstruction and thrombosis. The diagnosis is frequently missed and the clinical course can be dramatic and life threatening. Intravascular ultrasound (IVUS) is a very importante tool to identify IMH and should be available in complex cases interventions.

Changes in aortic root dimensions post aortic root enlargement with Y-incision and modified aortotomy.

Lifetime management in aortic stenosis (AS) can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve (ViV) procedures. A mitral valve-sparing ARE technique ("Y-incision") and sinotubular junction (STJ) enlargement ("roof" patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking. Among 78 patients who underwent ARE by Y-incision technique (± roof aortotomy closure) we identified 45 patients with high-quality pre- and post-operative computed tomography angiography (CTA) scans to allow analysis of change in aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses were performed by an expert imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annulus when a bioprosthetic valve was present. Average age was 65±11 years, the majority were female (29, 64%), and 9 (20%) had undergone prior aortic valve replacement (AVR). Valve upsizing was ≥3 sizes in 41 (91%). Post-operative mean basal ring diameter was larger compared to the native annular diameter (26.3 vs. 25.3 mm, P<0.01) and substantially larger than prior prosthetic valve in redo AVR (25.6 vs. 19.3 mm, P<0.001). Diameters of the sinuses at pre-operative computed tomography (CT) increased by +7.7±2.8 [right sinuses of Valsalva (R SVS)], +6.7±3.0 [left sinuses of Valsalva (L SVS)], and +6.6±2.9 mm [non-coronary sinuses of Valsalva (N SVS)]. Mean diameter of the STJ increased to 38.3±3.7 post-operative (+8.1±3.2 mm). Left main (LM) and right coronary artery (RCA) heights decreased by -6.3±3.3 and -3.7±3.4 mm respectively due to the supra-annular position of the valve, however, the post-operative valve-to-coronary (VTC) artery distances were 6.6±2.3 and 4.9±2.0 mm, respectively. The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 6-7 mm while preserving VTC distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV).

Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000

BackgroundAlthough a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined. ObjectivesAmong persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates. MethodsThe authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years). ResultsThe mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]). ConclusionsAmong asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

A New Scoring System Predicting Side-Branch Occlusion in Patients Undergoing Left Main Bifurcation Intervention: The LM V-RESOLVE Score

BackgroundThe risk of side-branch (SB) occlusion is pivotal for decision making of stenting strategies during unprotected left main (LM) bifurcation percutaneous coronary intervention (PCI). Accordingly, this study aimed to develop a scoring system for predicting SB occlusion during unprotected LM bifurcation PCI. MethodsA total of 855 consecutive patients undergoing unprotected LM bifurcation PCI with provisional strategy at Fuwai Hospital from January 2014 to December 2016 were recruited. A prediction model was selected by means of all-subsets logistic regression, and a multivariable risk score (Left Main Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [LM V-RESOLVE]) was then established with incremental weights attributed to each component variable based on its estimate coefficients. SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction (TIMI) flow grade or absence of flow in SB after main vessel (MV) stenting. ResultsSB occlusion occurred in 19 LM bifurcation lesions (2.22%). In multivariable model, 3 variables, including MV/SB diameter ratio, MV plaque ipsilateral to SB, and baseline diameter stenosis of SB, were independent predictors for SB occlusion (model C-statistic 0.829, 95% confidence interval [CI] 0.735-0.923, with good calibration). The risk score had a C-statistics of 0.830 (95% CI 0.738-0.923) with good calibration. Satisfactory discriminative ability of the risk score was also preserved in external validation (C-statistic 0.794, 95% CI 0.691-0.896). ConclusionsThe LM bifurcation–specific novel scoring system, LM V-RESOLVE, based on 3 simple baseline angiographic findings, could help to rapidly discriminate lesions at risk of SB occlusion during LM bifurcation PCI.

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

Optimal stent deployment in left main (LM) bifurcation is paramount, and incomplete stent apposition may cause major adverse cardiac events (MACE). Bench studies show that the proximal optimization technique (POT) provides the best stent apposition. We aimed to investigate the impact of POT on clinical outcomes in patients treated for unprotected LM (ULM) disease at our institution. We identified 162 patients who underwent percutaneous coronary intervention (PCI) for ULM coronary disease in the Cardio-FR database. Out of these, 99 (61%) had undergone POT, while 63 patients were treated without POT. The primary outcome was the bifurcation-oriented composite endpoint (BOCE) of cardiac death, target-bifurcation myocardial infarction and target-bifurcation revascularization at maximal follow-up. Mean age was 76 years, and 69% presented with acute coronary syndrome. Mean follow-up was 2.25 years (822 days). The BOCE occurred in 43 (27%) of which 20 (20%) in the POT group and 23 (37%) in the no-POT group (p = 0.009). Cardiac death occurred in 15 (15%) patients in the POT- and 17 (27%) in no-POT group (p = 0.26). Target bifurcation revascularization occurred in 4 (4%) patients in the POT- and 6 (10%) patients in the no-POT group (p = 0.19). POT In the multivariate analysis, POT was the strongest parameter and was associated with BOCE, cardiac death, occurrence of any revascularization and all-cause mortality. The POT improves clinical outcomes. These findings strongly support the systematic use of POT in patients undergoing ULM-PCI.

Predictors of prolonged hospital stay and in-hospital mortality in female patients with acute myocardial infarction with specific reference to diabetes

This study aimed to determine predictors of prolonged length of stay (LOS) and mortality in female STEMI patients with diabetes in comparison to female STEMI patients without diabetes. This retrospective single-center study was conducted between 2015 and 2020 as part of the STEMI registry in our center and included all STEMI patients. ResultsOut of 3081 STEMI patients, 16% (N = 498) were female, and 64% (n = 318) of them had diabetes. Diabetic patients were less commonly presented with anterior wall myocardial infarction (AWMI) (47% vs 65%, p = 0.001), but tended to have a higher prevalence of left main (LM) significant disease compared to non-diabetic patients (4% vs 1%, p = 0.06). Of the patients, 36% had prolonged LOS (≥5 days), and they were more obese with a higher incidence of hemoglobin drop ≥ 3 g/dL, higher admission troponin, and peak creatinine. 22% of patients with prolonged LOS came to the hospital after receiving lytic therapy and showed a higher prevalence of multivessel stenosis. Prolonged LOS patients had a higher incidence of pulmonary edema and cardiac arrest, which necessitated ventilation, although they did not show a significant difference in mortality from the group with LOS < 5 days. Our study found a significant negative correlation between glycosylated hemoglobin (HbA1c) and left ventricular ejection fraction (LVEF) (p = 0.02), but a positive correlation was noticed between HbA1c and LOS (p < 0.001). Regression analysis showed that diabetes mellitus, hemoglobin drop, creatinine level, and LVEF were significant predictors of prolonged LOS among females, although HbA1c, BMI ≥ 30, STEMI type, and peak creatinine level were independent predictors of prolonged LOS among female diabetic patients. Age ≥ 65 years and LVEF were significant independent predictors of mortality (p = 0.04, 0.02 respectively) in STEMI female patients. ConclusionsDiabetes mellitus, bleeding, renal impairment, and LVEF were found to be significant independent predictors of prolonged LOS among STEMI females. Age ≥ 65 years and LVEF were significant predictors of mortality among STEMI female patients.

Rationale and design of a prospective, open-label, randomized, multicentric clinical trial on the role of drug-coated balloons for bifurcation coronary lesions: the PRO-DAVID study

Background. Coronary bifurcation lesions (CBL) are associated with impaired outcome. The role of drug-coated balloons (DCB) in this setting has been only investigated in small studies so far. Aim. We here describe the design of PRO-DAVID study, aiming at investigating the clinical outcomes of a “provisional DCB” versus a "standard" approach (provisional or upfront two stent techniques) for the treatment of complex CBL. Methods and results. The PRO-DAVID trial is a prospective, open-label, randomized, multicentric clinical trial of the interventions with true CBL (Medina 1,0,1; 1,1,1; 0,1,1) of unprotected left main (LM), and non-left main (non-LM) CBL with affected significant side branche (SB). The study hypothesis is that a “provisional DCB approach” with PCI using first DCB in SB after optimal predilatation and then DES implantation in the main vessel will be non-inferior to standard bifurcation-PCI as per EBC recommendations. The calculated sample size is 602 patients in total, and allocation is 1:1. The primary study endpoint is a composite of cardiac death, target vessel MI, or clinically-driven target lesion revascularization (TLR) at 12 months, and patients will be followed up for up to 3 years. Implications. CBL management with stents only is associated with impaired outcome, and some preliminary data on the performance of DCB show their safety and efficacy in this setting. PRO DAVID study is an adequately powered randomized trial with clinical endpoints aimed to test DCB use in true CBL.

A more-Comers populAtion trEated with an ultrathin struts polimer-free Sirolimus stent: an Italian post-maRketing study (the CAESAR registry).

The use of contemporary drug-eluting stents (DES) has significantly improved outcomes of patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). However, concerns exist regarding the long-term proinflammatory effects of durable polymer coatings used in most DES, potentially leading to long-term adverse events. First-generation polymer-free stent technologies, such as sirolimus- and probucol-eluting stents (PF-SES), have shown an excellent safety and efficacy profile. The aim of this study was to evaluate the safety and efficacy of the new ultrathin Coroflex ISAR NEO PF-SES, in a more-comers PCI population. The CAESAR (a more-Comers populAtion trEated with an ultrathin struts polimer-free Sirolimus stent: An Italian post-maRketing study) registry is a multicenter, prospective study conducted in Italy, enrolling more-comers CAD patients undergoing PCI with the Coroflex ISAR NEO stent. Patients with left main (LM) disease, cardiogenic shock (CS), or severely reduced left-ventricular ejection fraction (LVEF) were excluded. The primary endpoint was target-lesion revascularization (TLR) at 1 year. A total of 425 patients were enrolled at 13 centers (mean age 66.9 ± 11.6 years, Diabetes mellitus 29%, acute coronary syndrome 67%, chronic total occlusion 9%). Of these, 40.9% had multivessel disease (MVD) and in 3.3% cases, the target lesion was in-stent restenosis (ISR). Clinical device success was reached in 422 (99.6%) cases. At 1 year, only two (0.5%) subjects presented ischemia-driven TLR. The 1-year rates of target vessel revascularization and MACE were 0.5% and 5.1%, respectively. Major bleeding was observed in four (1.0%) patients. In this multicenter, prospective registry, the use of a new ultrathin Coroflex ISAR NEO PF-SES in a more-comers PCI population showed good safety and efficacy at 1 year.