The role of final kissing balloon (FKB) inflation after simple crossover stenting in unprotected left main (LM) bifurcation stenosis remains unknown. From the Asan Medical Center-Left Main ...Revascularization (ASAN-MAIN) registry, 413 patients with LM bifurcation stenosis treated by simple crossover stenting with a drug-eluting stent were identified. After simple crossover stenting, FKB inflation was performed in 95 patients (FKB group) and 318 patients finished the procedure without FKB (no-FKB group). The primary end points of the 2-year incidence of major adverse cardiac events (death, myocardial infarction, and left main target lesion revascularization LM-TLR) were similar between the FKB and no-FKB groups (12.5% vs 8.5%, p = 0.24). After adjustment, the risk of major adverse cardiac event was not significantly different between the FKB and the no-FKB groups (hazard ratio HR 1.10, 95% confidence interval CI 0.49 to 2.49; p = 0.82). The risk of death (HR 1.03, 95% CI 0.28 to 3.82; p = 0.98), the composite of death or myocardial infarction (HR 0.95, 95% CI 0.26 to 3.51; p = 0.96), or LM-TLR (HR 1.32, 95% CI 0.46 to 3.75; p = 0.60) were not significantly different between groups. In conclusions, for the treatment for LM bifurcation stenosis, selective, not mandatory, FKB strategy after simple crossover stenting appears to be associated with a favorable outcome.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Clinical outcomes for unprotected left main coronary artery (ULMCA) disease between coronary artery bypass grafting (CABG) and drug-eluting stents (DESs) remain controversial. We aimed to compare the ...safety and efficacy of percutaneous coronary intervention (PCI) using DESs with CABG in patients with ULMCA disease. Databases were searched for clinical studies that reported outcomes after PCI with DESs and CABG for treatment of ULMCA disease. End points of this meta-analysis were mortality; composite of death, myocardial infarction (MI), or stroke; and target vessel revascularization at 1-year follow-up. Pooled effects were calculated using fixed-effects model (Mantel–Haenszel method) or random-effects models (Dersimonian–Laird method). Twelve clinical studies (3 randomized trials and 9 observational studies) with 5,079 patients were involved in this study. At 1-year follow-up, there were trends toward lower risk of death (odds ratio OR 0.68, 95% confidence interval CI 0.45 to 1.02) and the composite end point of death, MI, or stroke (OR 0.70, 95% CI 0.49 to 1.00) in the DES group compared to the CABG group. However, target vessel revascularization was significantly higher in the DES group compared to the CABG group (OR 3.52, 95% CI 2.72 to 4.56). In conclusion, PCI with DESs is associated with favorable outcomes for mortality; composite end point of death, MI, or stroke; and a higher risk of target vessel revascularization compared to CABG in patients with ULMCA disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Limited data are available on the impact of concomitant left main coronary artery disease (CAD) on mortality following revascularization of multivessel coronary artery disease alone (MVD) or ...multivessel plus left main coronary artery disase (MVLMD). This study compared long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in 2,887 patients with MVD or MVLMD. Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. The primary outcome was death due to any cause. Of the 2,887 patients, 1,975 (68.4%) were classified as having MVD and 912 (31.6%) as having MVLMD. The median follow-up duration was 60.2 months. In the MVD patients, primary outcome rate after CABG was significantly lower than after PCI (hazard ratio HR, 0.66; 95% confidence interval CI, 0.49−0.89; P=0.007). In the MVLMD patients, however, CABG and PCI showed similar primary outcome rates (HR, 0.98; 95% CI, 0.67−1.43; P=0.896). Among those who underwent CABG, primary outcome rate was lower in the MVD patients than in MVLMD patients (HR, 0.66; 95% CI, 0.46–0.95; P=0.024). Kaplan–Meier analysis showed a clear separation between the MVD and MVLMD patients 2.5 years after the index surgery. The risk of death due to any cause was significantly lower following CABG than following PCI with DES in MVD patients, but not in MVLMD patients. The advantage of CABG over PCI for multivessel CAD was significantly attenuated if concomitant left main CAD was present.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Coronary plaque composition cannot be assessed accurately using gray-scale intravascular ultrasound (IVUS). Using virtual histology IVUS (VH-IVUS), a comparison of coronary plaque composition between ...acute coronary syndromes (ACS) and stable angina pectoris (SAP) was performed. Preintervention IVUS of de novo culprit and target lesions was performed in 318 patients (123 with ACS and 195 with SAP). Using VH-IVUS, plaque was characterized as fibrotic, fibrofatty, dense calcium, and necrotic core. VH-IVUS-derived thin-cap fibroatheroma (VH-TCFA) was defined as necrotic core ≥10% of plaque area without overlying fibrous tissue in a plaque burden ≥40%. Lesions were classified into 3 groups: ruptured, VH-TCFA, and non–VH-TCFA plaque. Unstable lesions were defined as either VH-TCFA or ruptured plaque. Compared with patients with SAP, those with ACS had significantly more unstable lesions (89% vs 62%, p <0.001). Planar VH-IVUS analysis at the minimum luminal site and at the largest necrotic core site and volumetric analysis over a 10-mm-long segment centered at the minimum luminal site showed that the percentage of necrotic core was significantly greater and that the percentage of fibrofatty plaque was significantly smaller in patients with ACS. The percentages of fibrotic and fibrofatty plaque areas and volumes were smaller, and the percentages of necrotic core areas and volumes were larger in VH-TCFAs compared with non-TCFAs. Ruptured plaques in VH-IVUS analyses showed intermediate findings between VH-TCFAs and non–VH-TCFAs. In conclusion, culprit lesions in patients with ACS were more unstable and had greater amounts of necrotic core and smaller amounts of fibrofatty plaque compared with target lesions in patients with SAP.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background How statins alter the natural course of coronary atherosclerosis with compositional changes remains unclear. Objectives This study aimed to determine the effect of statin therapy ...on modifying plaque composition. Methods The STABLE (Statin and Atheroma Vulnerability Evaluation) prospective, single-center, double-blind, randomized study evaluated the effect of statins on functionally insignificant coronary stenoses. We randomly assigned 312 patients with a virtual histology (VH) intravascular ultrasound–defined fibroatheroma-containing index lesion to rosuvastatin 40 mg versus 10 mg (2:1 ratio). In 225 (72%) patients, grayscale- and VH-intravascular ultrasound were completed at baseline and 12 months. The primary endpoint was the change in VH-defined percent compositional volume within the target segment from baseline to follow-up in the per-protocol analysis set. Results Percent necrotic core (NC) volume within the target segment significantly decreased from 21.3 ± 6.8% to 18.0 ± 7.5% during 1-year follow-up, whereas the percent fibrofatty volume increased (11.7 ± 5.8% vs. 14.8 ± 9.3%; all p < 0.001). Percent fibrous (59.4 ± 7.8% vs. 59.2 ± 8.6%) and dense calcium (7.6 ± 5.1% vs. 7.8 ± 5.6%) volumes were unchanged. Frequencies of VH (55% vs. 29%) decreased significantly. Normalized total (202.9 ± 72.3 mm3 vs. 188.5 ± 67.8 mm3 ; p = 0.001) and percent (51.4 ± 8.3% vs. 50.4 ± 8.8%; p = 0.018) atheroma volumes decreased. Independent predictors of percent NC volume change were body mass index (β = 0.37; 95% confidence interval CI: 0.05 to 0.70), high sensitivity C-reactive protein (β = −3.16; 95% CI: −5.64 to −0.69), and baseline percent NC volume (β = −0.44; 95% CI: −0.68 to −0.19; all p < 0.05). VH-defined percent compositional volume changes in the rosuvastatin 40- and 10-mg groups were similar. Conclusions Rosuvastatin reduced NC and plaque volume and decreased thin-cap fibroatheroma rate. There were no significant differences between high- versus moderate-intensity rosuvastatin. (Statin and Atheroma Vulnerability Evaluation STABLE; NCT00997880 )
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Stenting for bifurcation lesions is still challenging, and the effect of intravascular ultrasound (IVUS) guidance on long-term outcomes has not been evaluated. We assessed the long-term outcomes of ...IVUS-guided stenting in bifurcation lesions. We evaluated 758 patients with de novo nonleft main coronary bifurcation lesions who underwent stent implantation from January 1998 to February 2006. We compared the adverse outcomes (i.e., death, stent thrombosis, and target lesion revascularization) within 4 years, after adjustment using a multivariate Cox proportional hazard model and propensity scoring. IVUS-guided stenting significantly reduced the long-term all-cause mortality (hazard ratio HR 0.31, 95% confidence interval CI 0.13 to 0.74, p = 0.008) in the total population and in the patients receiving drug-eluting stents (DESs) (HR 0.24, 95% CI 0.06 to 0.86, p = 0.03), but not in the patients receiving bare metal stents (HR 0.41, 95% CI 0.13 to 1.26, p = 0.12). IVUS-guided stenting had no effect on the rate of stent thrombosis (HR 0.48, 95% CI 0.16 to 1.43, p = 0.19) or target lesion revascularization (HR 1.47, 95% CI 0.79 to 2.71, p = 0.21). In patients receiving DESs, however, IVUS guidance reduced the development of very late stent thrombosis (0.4% vs 2.8%, p = 0.03, log-rank test). In conclusion, in patients receiving DESs, IVUS-guided stenting for treatment of bifurcation lesions significantly reduced the 4-year mortality compared to conventional angiographically guided stenting. In addition, IVUS guidance reduced the development of very late stent thrombosis in patients receiving DESs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The frequency and distribution of thin-cap fibroatheromas (TCFA) have important clinical implications. We evaluated the frequency and distribution of TCFA identified by virtual histology ...intravascular ultrasound (VH-IVUS) in acute coronary syndrome (ACS) and stable angina pectoris (SAP). Preintervention 3-vessel VH-IVUS was performed in 105 patients with ACS and 107 with SAP. The length of left anterior descending artery imaged was 72 ± 16 mm—54 ± 12 mm in the left circumflex and 92 ± 19 mm in the right coronary. VH-IVUS-derived TCFA (VH-TCFA) had a necrotic core ≥10% of plaque area without overlying fibrous tissue in a plaque burden ≥40%. There were 76 ruptured plaques (55 in ACS and 21 in SAP) and 439 VH-TCFA (262 in ACS and 177 in SAP, 2.5 ± 1.5 vs 1.7 ± 1.1 TCFA per patient with ACS and with SAP, respectively; p <0.001). Twelve patients with ACS and 1 with SAP had multiple ruptured plaques (p <0.001); 76 patients with ACS and 58 with SAP had multiple VH-TCFA (p = 0.009). Presentation of ACS was the only independent predictor for multiple ruptured plaques (p = 0.013) or multiple VH-TCFA (p = 0.011). Eighty-three percent of VH-TCFA were located within 40 mm of the coronary: 111 ≤10 (25%), 110 from 11 to 20 (25%), 83 from 21 to 30 (19%), and 61 from 31 to 40 mm (14%). The axial distribution of VH-TCFA was similar in patients with ACS and those with SAP and was similar to the axial distribution of ruptured plaques. In conclusion, 3-vessel VH-IVUS imaging showed a higher frequency of VH-TCFA in primary and secondary lesions in patients with ACS compared with those with SAP, but showed a similar clustering of VH-TCFA in the proximal 40 mm of each coronary artery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Periprocedural myocardial infarction (MI) can be induced by several angiographic mechanisms. However, there are limited data on whether these mechanisms differentially affect clinical outcomes. The ...purpose of our study was to investigate the impact of periprocedural MI on mortality according to the underlying angiographic mechanisms after drug-eluting stent (DES) implantation. We pooled the databases from 7 coronary stent trials using DES. Periprocedural MI was classified according to its underlying angiographic mechanisms as type 1 (due to side-branch occlusion), type 2 (due to other angiographic complications), or type 3 (without angiographically identifiable causes). Among 10,889 patients treated with DES, 768 (7.1%) experienced periprocedural MI; 463 cases (60.3%) were driven by type 1 cause, 138 (18.0%) by type 2 cause, and 167 (21.7%) by type 3 cause. Mortality rates at 2 years were higher in patients with periprocedural MI than in those without (3.5% vs 2.1%, respectively). Significant differences in mortality were observed according to the angiographic mechanisms of MI (type 1: 2.8% vs type 2: 6.1% vs type 3: 3.1%). After multivariable adjustment, type 2 MI was significantly associated with an increased risk of mortality (hazard ratio 2.65, 95% confidence interval 1.77 to 3.96), whereas type 1 and type 3 MI were not related with increased mortality. In conclusion, among patients receiving DES implantation, periprocedural MI was associated with increased mortality, and there were differential associations with mortality according to the underlying angiographic mechanisms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background In a previous randomized trial, we found that percutaneous coronary intervention (PCI) was not inferior to coronary artery bypass grafting (CABG) for the treatment of unprotected ...left main coronary artery stenosis at 1 year. Objectives This study sought to determine the 5-year outcomes of PCI compared with CABG for the treatment of unprotected left main coronary artery stenosis. Methods We randomly assigned 600 patients with unprotected left main coronary artery stenosis to undergo PCI with a sirolimus-eluting stent (n = 300) or CABG (n = 300). The primary endpoint was a major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) and compared on an intention-to-treat basis. Results At 5 years, MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%, respectively; hazard ratio HR: 1.27; 95% confidence interval CI: 0.84 to 1.90; p = 0.26). The 2 groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; 95% CI, 0.52 to 1.52; p = 0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%, respectively; HR: 2.11; 95% CI: 1.16 to 3.84; p = 0.012). Conclusions During 5 years of follow-up, our study did not show significant difference regarding the rate of MACCE between patients who underwent PCI with a sirolimus-eluting stent and those who underwent CABG. However, considering the limited power of our study, our results should be interpreted with caution. (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease PRECOMBAT; NCT00422968 )
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Even in the drug-eluting stent era, restenosis has remained an unresolved issue, particularly in the treatment of complex coronary lesions. In this study, patient-level data from 3 randomized trials ...(Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients With Diabetes Mellitus DECLARE-DIABETES and Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients With Long Native Coronary Lesions DECLARE-LONG I and II) were pooled to estimate the differential antirestenotic efficacy of add-on cilostazol according to the implanted drug-eluting stent in patients at high risk for restenosis. A total of 1,399 patients underwent sirolimus-eluting stent (SES; n = 450), paclitaxel-eluting stent (n = 450), and zotarolimus-eluting stent (n = 499) implantation and received triple-antiplatelet therapy (TAT; aspirin, clopidogrel, and cilostazol, n = 700) and dual-antiplatelet therapy (aspirin and clopidogrel, n = 699). Randomization of antiplatelet regimen was stratified by stent type. In-stent late loss after TAT was significantly lower than that after dual-antiplatelet therapy, regardless of implanted stent type. However, the incidence of in-segment restenosis after TAT was significantly lower with SES (0.5% vs 6.7%, p = 0.014) and zotarolimus-eluting stent (12.2% vs 20.0%, p = 0.028) implantation but not paclitaxel-eluting stent implantation (14.4% vs 20.0%, p = 0.244). A significant interaction was present between stent type and antiplatelet regimen for the risk for in-segment restenosis (p = 0.004). Post hoc analysis using bootstrap resampling methods showed that the relative risk reduction for in-segment restenosis after TAT was most prominent with SES implantation. In conclusion, add-on cilostazol effectively reduced restenosis in patients at high risk for restenosis, particularly in those receiving SES, suggesting the sustainable utility of add-on cilostazol therapy in newer generation drug-eluting stents with comparable efficacy with that of SES.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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