MedNexus
2022年 · 第02卷第03期
MedNexus
Coronary bifurcation lesion (CBL) is a narrowing of coronary artery adjacent to, and/or involving the origin of, a significant side branch. CBLs encompass a wide variety of anatomic subsets and clinical scenarios, from left-main bifurcation with a significant amount of myocardium at risk to a small branching lateral branch with a negligible amount of myocardium at risk. CBLs account for approximately 15% to 20% of all cases requiring percutaneous coronary intervention (PCI).[
The coronary left main (LM) artery is characterized by large caliber, length varying from <8 to >15 mm, and 2 large daughter vessels branching from it; it supplies blood to a large area (>75%) of the myocardium. LM bifurcation lesion is defined as the presence of atherosclerosis involving either or both of the 2 daughter vessels. Thus, the optimal strategy of revascularization for diseased LM has been an interesting research topic for a long time. With developments in percutaneous techniques, design, and materials of drug-eluting stents; intravascular imaging; new generation of antiplatelet medications; and particularly recent pooled evidence from randomized clinical trials comparing percutaneous coronary intervention with coronary artery bypass grafting, implantation of a drug-eluting stenting with or without other approved techniques is considered an important therapeutic approach for LM bifurcation lesions. Mirroring the anatomical complexity of the LM, stenting LM bifurcations is technically demanding, and intraprocedural complications can be catastrophic given the large amount of jeopardized myocardium. Therefore, the Chinese Society of Cardiology designed a writing committee with members from 3 working groups (ie, clinical research, intravascular imaging and physiology, and interventional cardiology) for the first time, to write a guideline on percutaneous treatment for LM bifurcation lesions, with view to improve the procedural quality and clinical outcomes. This guideline consists of introduction, anatomical description of the LM tree, risk stratification, strategies of revascularization, antiplatelet strategy, follow-up, and long-term management for patients with LM bifurcation lesions.
Reported data regarding the prevalence, prognostic impact, and safety and efficacy of revascularization of coronary chronic total occlusion (CTO) in patients with left main coronary artery (LMCA) disease who undergo percutaneous coronary intervention (PCI) are scarce. The aim of the present study was to compare clinical outcomes among patients with LMCA disease undergoing PCI. Outcomes were compared between those with and without coronary CTO and between those with CTO who had successful and unsuccessful CTO recanalization procedures.
All consecutive patients with significant LMCA disease (>50% stenosis at coronary angiography) who underwent PCI between July 2014 and December 2018 were retrospectively included in our study. The primary endpoint of the study was long-term mortality. Secondary endpoints included the incidence of myocardial infarction, repeat percutaneous or surgical revascularization, stroke, and stent thrombosis.
Between July 2014 and December 2018, 578 patients underwent PCI for LMCA disease at Pederzoli Hospital and University of Turin were enrolled. They were divided into 3 groups: group A: 374 (65%) patients without CTO, group B: 108 (19%) patients with untreated or unsuccessfully treated CTO, and group C: 96 (17%) patients with successfully treated CTO. At a median follow-up of (1090 ± 279) days, there were no statistically significant differences between the groups in terms of the primary and secondary endpoints. However, there was a trend towards higher mortality in patients with untreated or unsuccessfully treated CTO (13% vs. 19% vs. 14% in groups A, B, and C, respectively; P = 0.12). The primary and secondary endpoints were further analyzed based on the presence or absence of myocardial viability: subgroup C1: 54 (56%) patients with successful percutaneous transluminal coronary angioplasty (PTCA) having viability, and subgroup C2: 42 (44%) patients with successful PTCA not having viability. There was a trend toward a statistically significant higher rate of death among patients in group B, who underwent unsuccessful recanalization with viable myocardium (19% vs. 9% vs. 19% in groups B, C1, and C2, respectively, P = 0.05). On multivariable analysis, the propensity for successful revascularization of CTO was associated with a reduced risk of death (P = 0.01; odds ratio, 0.75; 95% confidence interval: 0.62-0.87).
Among patients with LMCA disease undergoing PCI, CTO represents a common finding associated with worse prognosis. Successful revascularization of CTO in patients with viable myocardium appears to significantly improve prognosis.
This study is aimed to analyze the long-term safety and effectiveness of second-generation cryoballoon (CB2) ablation in the treatment of atrial fibrillation (AF).
Data from 760 consecutive patients in the Department of Cardiology, General Hospital of Northern Theater Command from August 2016 to December 2018 with drug-refractory symptomatic AF undergoing pulmonary vein isolation (PVI) using CB2 were assessed. Procedure-related safety and freedom from AF and atrial flutter/atria tachycardia through 3 years were determined. The risk factors related to atrial tachyarrhythmia recurrence were analyzed.
Acute PVI was achieved in 100% of the 760 patients. Radiofrequency application for additional focal ablation was needed in 11 (1.4%) patients and for 14 pulmonary veins (0.5%, 14/(760×4)) to achieve PVI. A total of 748 patients, including 539 with paroxysmal AF (PAF) and 209 with persistent AF (SAF) completed the follow-up, and only 12 (1.6%) patients were lost. The mean follow-up duration was (19±8) months. The rate of major complications was 0.9%, including 0.8% of right phrenic nerve injury, which resolved before discharge. Freedom from all tachyarrhythmias was achieved in 75.0%, 69.4%, and 63.2% of patients with PAF, respectively, at 12-, 24-, and 36-month follow-up, and in 75.1%, 67.4%, and 60.9% for SAF, with no significant differences between the PAF and SAF groups. AF course and the rate of body weight gain were independent risk factors for recurrence at 12 months after ablation (P = 0.001 and P = 0.009, respectively).
PVI using CB2 has a high acute success rate and good safety in the treatment of PAF and SAF. Long course of AF and weight gain after ablation were independent risk factors for recurrence.
The optimal percutaneous coronary intervention (PCI) technique for bifurcation lesions remains controversial, especially considering the variability of the side branch (SB). A provisional stenting technique is currently recommended in most cases. This meta-analysis aimed to compare outcomes of different bifurcation PCI strategies, clarifying their scope of application.
Randomized controlled trials comparing PCI strategies for coronary bifurcation lesions were systematically retrieved from PubMed, Cochrane, Web of Science, and EBSCO literature databases without limitations on published date or language. Major adverse cardiovascular events (MACEs) were stipulated as main outcomes. Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, target lesion revascularization (TLR), target vessel revascularization, myocardial infarction (MI), and stent thrombosis. Both pooled analysis and sub-group analysis were performed.
Twenty-three randomized controlled trials with 6380 participants were included. Eighteen studies compared the provisional strategy with 2-stent approaches. No significant difference in MACEs (relative risk (RR), 1.16; 95% confidence interval (CI), 0.90-1.48; I2 = 62%) was found between 1-stent and 2-stent techniques. However, when SB lesion length was used as the separation condition, the 2-stent strategy was associated with fewer MACEs (RR, 1.87; 95% CI, 1.46-2.41; I2 = 70%), TLRs (RR, 2.13; 95% CI, 1.50-3.02; I2 = 59%), and MIs (RR, 2.17; 95% CI, 1.19-3.95; I2 = 52%) than the provisional strategy in those where SB lesions measured >10 mm long.
In the current work, there was no significant difference between 1-stent and 2-stent techniques in terms of MACEs or secondary outcomes. However, 2-stent approaches have clinical advantages over the provisional strategy in bifurcation when the SB lesion length is >10 mm due to fewer cases of TLR and MI.
Double kissing (DK) crush stenting for coronary bifurcation lesions has gain popularity worldwide because of its superior randomized studies data and excellent clinical outcomes. This review evaluates all DK crush clinical trials and studies. It also reveals the contemporary technique steps by steps as well as the trouble shooting with illustrated clinical scenarios. Among all the available evidence, the DK crush technique is superior when compared to the provisional stenting technique for complex bifurcation lesion. DK crush stenting provides the best evidence-based approach to complex bifurcation lesions especially the left main coronary artery bifurcation lesions. Future direction of how to make this DK crush technique better is also proposed.
Coronary bifurcation lesions (CBL) are one of the most challenging lesions to treat in interventional cardiology. Intravascular imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) is paramount for the assessment of lesion characteristics and suboptimal stent results and to improve the outcome of percutaneous coronary intervention (PCI). After upgrading the use of IVUS and OCT by the American College of Cardiology/American Heart Association guidelines, their use has increased. Likewise, there has been significant improvement in image quality and the profile of system (ie, IVUS catheter size). The main indication for the use of IVUS includes: assessment of lesion characteristics, optimization of stent deployment, optimal stent expansion, exclusion of plaque burden >50%, and edge dissection. Intravascular imaging plays a significant role in the assessment and treatment of left main (LM) coronary artery stenosis and CBL. In particular, the use of intravascular imaging for alleviating mechanical issues during stenting and managing stent thrombosis has significantly increased. Overall, a compelling body of evidence has shown that the use of IVUS or OCT during PCI leads to optimal stenting results and mitigates the risk of adverse cardiac events. However, to date, the American College of Cardiology/American Heart Association Guidelines have assigned a Class IIb recommendation for IVUS or OCT, while the European Society of Cardiology Guidelines upgraded it to the Class IIa recommendation. This review summarized the role of IVUS and OCT for the assessment of stenosis and stent optimization in patients with CBL and LM stenosis. In addition, we discuss new insights into the role of IVUS- and OCT-guided stenting in patients with CBL and LM stenosis provided by the ongoing randomized trials.
Bifurcation lesions are encountered and treated in up to 1 in 5 cases of percutaneous coronary intervention (PCI). Such lesions pose a technical challenge to PCI, leading to lower procedural success and a higher rate of long-term adverse events. However, each bifurcation is unique in terms of anatomy and pathological presentation. There is no "one size fits all" strategy for coronary bifurcation PCI. Nevertheless, in most scenarios, provisional stenting is the preferred technique. This method is easy to apply and involves a logical stepwise escalation approach that is highly successful and safe.
Alcoholic cardiomyopathy (ACM) is a dilated cardiomyopathy induced by excessive alcohol consumption that causes progressive cardiac dysfunction and chamber dilatation, leading to arrhythmias, heart failure, and death. Cardiac transplantation is the final measure for end-stage ACM. In this case, we used multimodal imaging for ACM diagnosis in a patient with refractory heart failure. The patient received a heart transplant with a good prognosis, and his pathological results after the transplant confirmed our suspected diagnosis. End-stage ACM may lead to refractory heart failure and multimodal imaging may play an important role in the diagnosis, prognosis prediction, and follow-up study of suspected ACM.
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