Crush is superior to Culotte in two-stent strategy for treatment of left main coronary artery bifurcations: A systematic review and meta-analysis

Purpose: Crush and Culotte techniques have been used increasingly to treat patients with complex unprotected left main coronary artery bifurcation lesions. This article compares published data on these two techniques. Methods: Databases, including PubMed, Embase, Cochrane Library, Wanfang Data and China National Knowledge Infrastructure, were searched for articles published before Aug 21, 2019 to identify all relevant studies on left main coronary artery bifurcation lesions treated by Crush versus Culotte techniques. The pooled data were analyzed using either fixed- or random-effects model depending on heterogeneity (assessed via the I2 index). The endpoints were major adverse cardiac events, target lesion revascularization, cardiac death, stent thrombosis, myocardial infarction and target vessel revascularization. Results: Eight articles with a total of 1,283 patients were included, and 710 patients were treated with Crush, and 573 ones with Culotte. Crush group was trend to decreased major adverse cardiac event compared with Culotte group [Relative ratio (RR) 0.63,95% confidence interval(CI) 0.39-1.04, I2 =72.7%], mainly driven by decreased cardiac death [RR 0.49, 95% CI(0.25-0.99), I2 =0%], decreased myocardial infarction [RR 0.40, 95% CI(0.21-0.76), I2 =21.6%],and lower stent thrombosis [RR 0.39, 95% CI(0.16-0.98), I2 =39.4%]. There was no significant difference in target lesion revascularization and target vessel revascularization between Crush and Culotte [RR 0.77, 95% CI 0.46-1.28, I2=61.1%; RR 0.78, 95% CI (0.30-2.02), I2 =73.1%, respectively]. Conclusion: Crush was superior to Culotte for treatment of left main coronary artery bifurcation lesions with a trend of lower incidence of long-term major adverse cardiac events, mainly derived from decreased myocardial infarction, stent thrombosis and cardiac death.

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Abstract 14575: Systematic Review and Meta-analysis of Intravascular Ultrasound-guided Percutaneous Left-main Coronary Artery Intervention

Circulation ◽

10.1161/circ.142.suppl_3.14575 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sameer Saleem ◽

Shuaibahmed Arab ◽

Waqas Ullah ◽

Sundas Younas ◽

Bashar Al hemyari ◽

...

Keyword(s):

Myocardial Infarction ◽

Systematic Review ◽

Coronary Artery ◽

Stent Implantation ◽

Cardiac Death ◽

Left Main Coronary Artery ◽

Meta Analysis ◽

Ultrasound Guided ◽

Left Main ◽

Relative Odds

Introduction: Previous meta-analyses have reported reduced cardiovascular mortality and myocardial infarction in intravascular ultrasound-guided (IVUS) stent implantation in comparison to angiography-only approach. However, these studies have unanimously excluded patients with unprotected left-main coronary artery (LMCA) disease, questioning its widespread applicability. We performed a systematic review and meta-analysis to investigate the prognostic significance of IVUS-guided LMCA intervention. Methods: Studies comparing clinical outcomes between IVUS-guided and angiography-only percutaneous LMCA intervention were identified through PubMed, Cochrane and EMBASE databases until June, 2020. Data was analyzed using a random effect model to calculate the relative odds of all-cause death, cardiac death, left-main revascularization, myocardial infarction, stent thrombosis and stroke. Results: A total of 13 studies comprising 7680 patients were included. The odds of all-cause death (OR 0.6, 95%CI 0.47-0.78; p<0.0001), cardiac death (OR 0.37, 95%CI 0.26-0.54; p<0.00001), left-main revascularization (OR 0.63, 95%CI 0.45-0.89; p=0.009) and myocardial infarction (OR 0.77 [95%CI 0.60-0.98; p=0.04]) were significantly lower in patients who underwent IVUS-guided LMCA stent implantation compared to angiography-only approach. There was no significant difference observed in the relative odds of stent thrombosis (OR 0.57, 95%CI 0.31-1.05; p=0.07) and stroke (OR 1.7, 95%CI 0.56-5.14; p=0.35) between the two arms at least 1-year of the index procedure. A subgroup analysis based on study design and sensitivity analysis based on the characteristics of the included studies mirrored the pooled results. Conclusion: IVUS-guided LMCA intervention is associated with overall improved cardiovascular outcomes than angiography-only approach. Large scale randomized controlled trials are needed to validate our findings.

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Two-Year Outcomes after Left Main Coronary Artery Percutaneous Coronary Intervention in Patients Presenting with Acute Coronary Syndrome

Journal of Interventional Cardiology ◽

10.1155/2020/6980324 ◽

2020 ◽

Vol 2020 ◽

pp. 1-8

Author(s):

Si-Da Jia ◽

Yi Yao ◽

Ying Song ◽

Xiao-Fang Tang ◽

Xue-Yan Zhao ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Coronary Artery ◽

Left Main Coronary Artery ◽

Coronary Intervention ◽

Target Lesion ◽

Left Main ◽

Coronary Syndrome ◽

Percutaneous Coronary

Objectives. We aim to evaluate long-term outcomes after left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). Background. PCI of the LMCA has been an acceptable revascularization strategy in stable coronary artery disease. However, limited studies on long-term clinical outcomes of LMCA PCI in ACS patients are available. Methods. A total of 6429 consecutive patients with ACS undergoing PCI in Fuwai Hospital in 2013 were enrolled. Patients are divided into LMCA group and Non-LMCA group according to whether the target lesion was located in LMCA. Prognosis impact on 2-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed. Results. 155 (2.4%) patients had target lesion in LMCA, while 6274 (97.6%) patients belong to the non-LMCA group. Compared with non-LMCA patients, LMCA patients have generally more comorbidities and worse baseline conditions. Two-year follow-up reveals that LMCA patients have significantly higher rate of cardiac death (2.6% vs. 0.7%, p=0.034), myocardial infarction (7.1% vs. 1.8%, p<0.001), in-stent thrombosis (4.5% vs. 0.8%, p<0.001), and stroke (7.1% vs. 6.4%, p=0.025). After adjusting for confounding factors, LMCA remains independently associated with higher 2-year myocardial infarction rate (HR = 2.585, 95% CI = 1.243–5.347, p=0.011). Conclusion. LMCA-targeted PCI is an independent risk factor for 2-year myocardial infarction in ACS patients.

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279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

European Heart Journal ◽

10.1093/eurheartj/ehz747.0084 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

G Di Gioia ◽

J Sonck ◽

I Colaiori ◽

T Mizukami ◽

M Kodeboina ◽

...

Keyword(s):

Myocardial Infarction ◽

Stent Thrombosis ◽

Cardiac Death ◽

Meta Analysis ◽

Evaluation Framework ◽

Left Main ◽

Coronary Bifurcation ◽

Bifurcation Lesions ◽

Provisional Stenting ◽

Crush Technique

Abstract Background The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines. Purpose To compare the clinical outcome between different bifurcation PCI techniques. Methods We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis. Results We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques. Conclusions In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

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Effectiveness and prognostic value of intravscular imaging in patients with left main coronary artery stenosis and heart failure

European Heart Journal ◽

10.1093/eurheartj/ehab724.2077 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

D Maximkin ◽

Z Shugushev ◽

A Chepurnoy ◽

J M Bolivougui ◽

A Faybushevich ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Artery ◽

Prognostic Value ◽

Left Main Coronary Artery ◽

Terminal Part ◽

Left Main ◽

Cardiac Events ◽

Group 2 ◽

Group 1

Abstract Aims A comparative analysis and evaluate the effectiveness and prognostic value of optical coherence tomography (OCT) and fractional flow reserve (FFR) guiding measurement in patients with stenosis of the terminal part of the left main coronary artery (LMCA). Methods 222 patients were selected in the study. Inclusion criteria: true bifurcation stenosis of the LMCA according to quantitative coronary angiography (QCA) and classification by A. Medina. Criteria for determining the hemodynamic significance of stenosis: according OCT - minimal lumen area (MLA) in the terminal part of LMCA <6 mm2; according FFR guiding – <0.8 (in LCx or LAD or both). Patients, who have not been diagnosed hemodynamically significant stenosis, were further subjected to the dynamic observation. All received optimal medical therapy. The study continued to participate patients whose compliance to receive drugs was not lower than 80%. Primary endpoints: frequency of MACE (death, myocardial infarction, revascularizations). The follow-up were 12, 24, 36 months. Results The OCT was performed in 110 patients and FFR guiding measurement – in 112 patients. According to the OCT, were hemodynamically significant stenoses are determined in 36 (32.7%) patients and after FFR-guiding measurement – in 32 (28.6%) of patients (χ2=2.184 p>0.05). Patients without hemodynamically significant stenoses distributed into 2 groups: group 1 (n=74) – according to the OCT and group 2 (n=80) – according to the FFR. The long-term results were monitored in all patients. The frequency of myocardial infarction in group 1 were 1.4% and in group 2 – 7.5% (p<0.05).The frequency of revascularization in group 1 were 5.4% and in group 2 – 15% (p<0.05). The total frequency of major cardiac events were 6.75% in group I and 22.5% in group II (χ2=6.435; p<0.001). The survival without major cardiac events (Kaplan-Maier analysis) were significantly differ between the groups, of 93.25% in group 1 and 77.5% – in group 2 (χ2=7.162 p<0.001). Conclusions The effectiveness of the OCT imaging and the FFR-guiding measurement in determining the hemodynamic significance of the bifurcation stenosis of the LMCA, not different. However, in the long term period, patients with insignificant stenosis identified by the FFR, have a worse prognosis and are distinguished by a major cardiac events, compared with the OCT, which does not allow us to recommend the FFR method as the main one for determining the hemodynamic significance of LMCA. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100

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Impact of SYNTAX score 2 on 7-year clinical outcomes in patients treated with cobalt-chromium everolimus-eluting stent

European Heart Journal ◽

10.1093/ehjci/ehaa946.2531 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

T Hiromasa ◽

S Kuramitsu ◽

K Yamaji ◽

T Domei ◽

M Hyodo ◽

...

Keyword(s):

Myocardial Infarction ◽

Clinical Outcomes ◽

Stent Thrombosis ◽

Cumulative Incidence ◽

Cardiac Death ◽

Target Lesion ◽

The Other ◽

Syntax Score ◽

Cobalt Chromium ◽

Cardiac Events

Abstract Background Impact of SYNTAX score II (SSII) on long-term clinical outcomes after cobalt-chromium everolimus-eluting stent (CoCr-EES) implantation remains unclear. Methods Between February 2010 and May 2011, 1064 consecutive patients with 1440 lesions were treated only with CoCr-EES implantation. Of these, the SSII was calculated in 1013 patients with 1345 lesions. Patients were divided into the tertile group: Tertiles for SSII (low SSII [12–28.9], n=334; intermediate SSII [29–39.1], n=339; and high SSII [39.2–80.8], n=340). We assessed the cumulative 7-year incidences of major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, definite stent thrombosis, and clinically driven target lesion revascularization (CDTLR) based on SSII groupings. Results Cumulative 7-year incidence of MACE was significantly higher in the high SSII group than in the other groups (34.1% vs. 18.6% vs. 17.2%, p<0.001). The cumulative incidence of cardiac death, myocardial infarction and stent thrombosis were significantly higher in the high SSII group than in the other groups (22.1% vs. 2.0% vs. 5.3%, p<0.001; 6.6% vs. 4.9% vs. 1.7%, p=0.01; 2.9% vs. 1.7% vs. 0.3%, p=0.03, respectively). The cumulative incidence of CDTLR was similar between the groups (15.2% vs. 12.8% vs. 15.7%, p=0.57). High SSII group (hazard ratio [HR] 2.18 [vs. low SS], 95% confidence intervals [CI]: 1.56–3.06, p<0.001) and diabetes mellitus (HR 1.37, 95% CI: 1.04–1.81, p=0.03) were predictors of 7-year MACE. Conclusions SSII has significantly impact on 7 years clinical outcomes after CoCr-EES implantation. Cumulative incidence of MACE Funding Acknowledgement Type of funding source: None

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Electrocardiographic features in patients with acute myocardial infarction associated with left main coronary artery occlusion

Heart ◽

10.1136/hrt.2003.026799 ◽

2004 ◽

Vol 90 (9) ◽

pp. 1059-1060 ◽

Cited By ~ 26

Author(s):

S Kurisu

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Coronary Artery ◽

Left Main Coronary Artery ◽

Coronary Artery Occlusion ◽

Artery Occlusion ◽

Left Main

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A Case of Left Main Coronary Artery Disease in an Octogenarian Treated Surgically and Complicated by Myocardial Infarction: Decisions, Techniques, Rescue and Final Outcome

Clinical Medicine Insights Case Reports ◽

10.4137/ccrep.s11542 ◽

2013 ◽

Vol 6 ◽

pp. CCRep.S11542

Author(s):

Antoine Kossaify ◽

Gilles Grollier

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Left Main Coronary Artery ◽

Bypass Graft ◽

Left Main ◽

Coronary Syndrome ◽

Left Anterior Descending Artery ◽

Main Coronary Artery Disease ◽

Artery Disease

We report on an octogenarian patient presenting with an acute coronary syndrome due to significant left main coronary artery disease and severe ostial stenosis of the left anterior descending artery disease. Emergent bypass graft performed with “beating heart” consisted of left internal mammary graft to the mid left anterior descending artery with an “over-stent” anastomosis. The immediate post-operative phase was simple, however the patient presented on post-operative day 8 with extensive anterior myocardial infarction and cardiogenic shock. Emergent coronary angiogram showed subocclusive anastomotic stenosis. Percutaneous coronary intervention was performed on left main, proximal left anterior descending, and proximal circumflex arteries. Subsequently, the patient restored a satisfactory hemodynamic condition. A focus on the importance of decision for management of left main disease especially in octogenarian is presented, along with a review of the pertinent literature.

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