Abstract 17278: Mid-Term Clinical Outcomes of Functionally-Guided Treatment of Coronary Bifurcation Lesions

Background: Rates of major adverse cardiac events (MACE) after functionally guided percutaneous coronary intervention (PCI) of coronary bifurcation lesions have not been specifically analysed. Methods: Patients from FIESTA registry (ClinicalTrials.govNCT01724957) with stable angina, bifurcation lesions in a coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm and SB diameter≥2.0 mm were included in the analysis. Subjects with ST-segment elevation myocardial infarction, left main disease, hemodynamic instability were excluded. Provisional stenting was the default strategy in all patients. Fractional flow reserve (FFR) was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). Bifurcation lesion with FFR above 0.80 were deferred from PCI. Follow-up for vital status at every 3-month period was performed and rates of MACE, including cardio-vascular death, nonfatal myocardial infarction and stroke, were analyzed. Results: Overall 165 patients were included, mean age was 67±10 years, 66% males, 72 (44%) had functionally significant bifurcation lesions (FSL) and 93 (56%) were with non-significant lesions (nFSL). There were no differences (FSL vs. nFSL) regarding: dyslipidemia (88% vs 96%), diabetes (44% vs. 32%), smoking (52% vs 40%), previous MI (24% vs 15%), previous PCI (54% vs 49%), atrial fibrillation (17% vs 29%), PAD (10% vs. 9%), renal failure (29% vs 31%) – all p>0.05. On a median follow-up of 34±14 months there were no differences between FSL and nFSL regarding rates of cardio-vascular death -12.5% (n=9/72) vs. 7.5% (n=7/93), p=0.4, MACEs - 13.9% (n=10/72)vs 8.6 (8/93), p=0.512. On multivariate Cox-regression analysis factors associated with occurrence of MACE were: presence of cancer OR 3.692, (CI 0.955-14.269); renal failure OR 2.550, (CI 0.961-6.767) SYNTAX ≥9 OR 1.836, (CI 0.490-6.874); SB RVD ≥ 2.4mm OR 2.546, (CI 0.708-9.160); SB BARI 13.5% OR 2.013, (CI 0.652-6.211); WBC≥7OR 3.647, (CI 0.824-16.134); Platelet count ≥ 256.106/ml OR 3.814, (CI 1.220-11.925). Conclusion: Less than a half of angiographically significant coronary bifurcation lesions were functionally significant requiring stent implantation. The rates of MACE were not-significantly different in deferred and treated stenoses up to 3 years follow-up.

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P1963The determinants of functional significance of coronary bifurcation lesions and its implications on clinical follow up to 48 months (insights from FIESTA registry)

European Heart Journal ◽

10.1093/eurheartj/ehz748.0710 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D Vassilev ◽

P Nikolov ◽

N Mileva ◽

G Zlatancheva ◽

G Dimitrov ◽

...

Keyword(s):

Myocardial Infarction ◽

Functional Significance ◽

Selection Strategy ◽

Syntax Score ◽

Coronary Bifurcation ◽

Coronary Bifurcation Lesions ◽

Co Morbidity ◽

Main Vessel ◽

Bifurcation Lesions

Abstract Background There is no study up-to-now to determine the rate of functionally significant coronary bifurcation lesions, which have to be intervened and what are the clinical consequences of the FFR case selection strategy. Methods We analyzed patients from FIESTA registry, which was continuation of FIESTA study (Ffr vs. IcEcgSTA, ClinicalTrials.gov Identifier: NCT01724957). Patients with stable angina were included (if there were other coronary stenoses they were threated first after checking by FFR for functional significance). The inclusion criterions were angiographic bifurcation lesions in a native coronary artery with diameter ≥2.5 mm and ≤4.5 mm and SB diameter ≥2.0 mm. We excluded patients with ST-segment elevation myocardial infarction, left main, hemodynamic instability and those with non-cardiac co-morbidity conditions with a life expectancy of less than one year. PCI was performed according to the current guidelines. Provisional stenting was the default strategy in all patients. Two guidewires were inserted into both distal MB and SB. Initial FFR was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). For all FFR measurements, intracoronary adenosine was given in increasing doses of 60 mcg, 120 mcg, and 240 mcg. The minimum value of FFR measurements was taken for analysis. All patients received double antiplatelet therapy with ADP-antagonist and aspirin for at least 12 months. Results A 130 consecutive patients with coronary bifurcation stenoses were included – 57 had positive FFR<.80 in main vessel of bifurcation lesion (44% functionally significant lesions). The mean age was 67±10 years, 66% males, 96% hypertensive, 39% diabetic, 96% dyslipidemic (or on treatment with statin), 55% smokers, 22% with previous myocardial infarction, 51% with previous PCI. The residual SYNTAX score before FFR bifurcation assessment was 13±4 (FFR<.80) vs. 8±3 (FFR≥0.80), p<0.001. Univariate predictors of bifurcation FFR<.80 were: proximal (MV%DS) or distal (MB%DS) main vessel stenosis ≥85% (derived from ROC analysis with overall accuracy 77% and 72%, accordingly), lesion length, SYNTAX score, triglyceride concentration, previous MI on lateral wall and carotid artery disease. On multivariate logistic analysis only MV%DS>85% (OR=8.929, CI 2.887–27.619, p<0.001), MB%DS>85% (OR=3.831, CI 1.349–10.883, p=0.012) and SYNTAX score≥12 (OR=16.466, CI 5.225–15.889, p<0.001). At median follow-up of 26 months (IQR 17–35) the all-cause mortality was 17.5% in FFR positive bifurcations vs. 4.1% in FFR negative lesions (log-rank =.067). Conclusions Less than a half of angiographically significant coronary bifurcation lesions are functionally significant and require stent implantation. The functional significance was related with higher degree stenosis in main vessel and overall disease severity estimated with SYNTAX score. A trend to lower mortality was noted in group with non-significant FFRs.

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An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with A Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study

Medicina ◽

10.3390/medicina56030102 ◽

2020 ◽

Vol 56 (3) ◽

pp. 102

Author(s):

Mustafa Yurtdaş ◽

Ramazan Asoğlu ◽

Mahmut Özdemir ◽

Emin Asoğlu

Keyword(s):

Myocardial Infarction ◽

Side Branch ◽

Coronary Bifurcation ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

Coronary Bifurcation Lesions ◽

St Segment ◽

Bifurcation Lesions

Background and Objectives: Little is known about the upfront two-stent strategy (U2SS) for true coronary bifurcation lesions (CBLs) in acute coronary syndrome (ACS). We aimed to present our two-year follow-up results on the U2SS by using different two-stent techniques for the true CBL with a large side branch (SB) in ACS patients, including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), and to identify independent predictors of the presence of major adverse cardiac events (MACEs) after intervention. Materials and Methods: The study included 201 consecutive ACS patients with true CBLs who underwent percutaneous coronary intervention (PCI) using U2SS from October 2015 to March 2018. Clinical outcomes at follow-up were assessed. MACE was defined as a composite of cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Results: 31.3% of the patients had an UA, 46.3% had an NSTEMI, and 22.4% had an STEMI. CBL was most frequently located in the left anterior descending (LAD)/diagonal artery (59.2%). In total, 71.1% of the patients had a Medina classification (1,1,1). Overall, 62.2% of cases were treated with mini-crush stenting. Clopidogrel was given in 23.9% of the patients; 71.1% of the patients received everolimus eluting stent (EES); and 11.9% received a sirolimus eluting stent (SES). Final kissing balloon inflation was carried out in all patients, with an unsatisfactory rate of 5%. A proximal optimization technique sequence was successfully carried out in all patients. The MACE incidence was 16.9% with a median follow-up period of 2.1 years. There were seven cardiac deaths (3.5%). The TLR rate was 13.4% (n = 27), with PCI treatment in 16 patients, and coronary artery bypass grafting treatment in 11 patients. After multivariate penalized logistic regression analysis (Firth logistic regression), clopidogrel use (odds ratio (OR): 2.19; 95% confidence interval (CI): 0.41–2.51; p = 0.007) and SES use (OR: 1.86; 95% CI: 0.31–2.64; p = 0.014) were independent predictors of the presence of MACE. Conclusion: U2SS is feasible and safe for the true CBLs with large and diseased SB in ACS patients, and is related to a relatively low incidence of MACE. Clopidogrel use and SES use may predict the MACE development in ACS patients treated using U2SS.

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