Impact of atrial fibrillation on long-term outcomes in patients with coronary artery bifurcation lesions undergoing percutaneous coronary intervention

<p><strong>Background.</strong> Atrial fibrillation is one of the most common types of cardiac arrhythmias. The frequent combination of atrial fibrillation and coronary artery disease in clinical practice can be attributed to common risk factors and relationships among pathogenetic mechanisms.</p><p><strong>Aim. </strong>This study aims to evaluate the impact of atrial fibrillation on immediate and long-term clinical outcomes in patients undergoing percutaneous coronary intervention for coronary bifurcation lesions.</p><p><strong>Methods.</strong> This study included 709 patients who underwent percutaneous coronary intervention for coronary bifurcation lesions. All patients were divided into two groups: those with and without atrial fibrillation.</p><p><strong>Results.</strong> This multicentre registry showed that the incidence of atrial fibrillation was 11.7%. Compared to patients without a history of atrial fibrillation, those that did were older (66.8 ± 8.5 vs. 62.9 ± 9.0 years, p = 0.0002) and more often had cerebrovascular (22.9% vs. 10.4%, p = 0.003) and peripheral artery disease (18.1% vs. 7.2%, p = 0.002). The overall incidence of major adverse cardiovascular events at the hospital stage was 1.8%. The average follow-up duration was 476 ± 94 days. No difference in long-term major adverse cardiovascular events (15.0% vs. 13.1%, p = 0.6) was observed between patients with and without atrial fibrillation. Patients with atrial fibrillation were more likely to have adverse events, such as bleeding (13.8% vs. 9.3%, p = 0.22), stroke (2.5% vs. 1.0%, p = 0.23) and myocardial infarction (7.6% vs. 5.0%, p = 0.28), although differences between the groups were insignificant.</p><p><strong>Conclusion.</strong> Atrial fibrillation was not associated with mortality and major adverse cardiovascular events in patients undergoing percutaneous coronary intervention for coronary bifurcation lesions.</p><p><strong>ClinicalTrials.gov Identifier: </strong>NCT03450577</p><p>Received 4 August 2021. Revised 27 September 2021. Accepted 28 September 2021.</p><p><strong>Funding: </strong>The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Contribution of the authors<br /> </strong>Conception and study design: D.A. Khelimskii, O.V. Krestyaninov, A.G. Badoian, A.A. Baranov, R.B. Utegenov, I.S. Bessonov, S.S. Sapozhnikov<br /> Data collection and analysis: D.A. Khelimskii, A.G. Badoian, A.A. Baranov, R.B. Utegenov, I.S. Bessonov, S.S. Sapozhnikov<br /> Statistical analysis: D.A. Khelimskii, A.G. Badoian, I.S. Bessonov<br /> Drafting the article: D.A. Khelimskii, O.V. Krestyaninov, A.G. Badoian, A.A. Baranov, R.B. Utegenov, I.S. Bessonov, S.S. Sapozhnikov<br /> Critical revision of the article: D.A. Khelimskii, O.V. Krestyaninov, A.G. Badoian, A.A. Baranov, R.B. Utegenov, I.S. Bessonov, S.S. Sapozhnikov<br /> Final approval of the version to be published: D.A. Khelimskii, O.V. Krestyaninov, A.G. Badoian, A.A. Baranov, R.B. Utegenov, I.S. Bessonov, S.S. Sapozhnikov</p>

Stenting techniques for coronary bifurcation disease: a systematic review and network meta-analysis demonstrates superiority of double-kissing crush in complex lesions

Objective This study was aimed to compare different stenting techniques for coronary bifurcation disease (CBD). Background Percutaneous coronary intervention (PCI) remains controversial for CBD; over the years, several stent techniques for bifurcation lesions have been used. Current guidelines recommend a provisional single-stent strategy as the preferred method for coronary artery bifurcation lesions. However, several randomized controlled trials (RCT) indicated that two-stent techniques showed better clinical outcomes. Methods We systematically searched Embase, PubMed, and Web of Science to include RCTs. The primary endpoint was the major adverse cardiovascular event (MACE). Secondary outcomes were cardiac death, myocardial infarction (MI), target-lesion or target-vessel revascularization (TLR or TVR), and definite or probable stent thrombosis (ST). Finally, we used 26 RCTs and a total of 7257 individuals were randomly assigned to one of the 6 stent techniques and included in this network meta-analysis. Results In our network meta-analysis, double-kissing (DK) crush was significantly more superior to other 5 stent techniques in MACEs: OR vs. provisional 0.40 (95% CI 0.28–0.55); vs. culotte 0.40 (95% CI 0.26–0.60). DK crush ranked the most effective treatment for MACE (100%), MI (75%), ST (83%), and TLR (100%) in the rank probabilities analysis. In patients with complex bifurcation lesion defined by DEFINITION criteria, DK crush was notably more efficacious than provisional, culotte, and T-stenting/T-stenting and protrusion (TAP) in MACEs (OR vs. provisional 0.26, 95% CI 0.13–0.52) and TLR (OR vs. provisional 0.24, 95% CI 0.10–0.58). Conclusion Compared with other stenting techniques, DK crush had a lower incidence of MACEs in CBD. DK crush was significantly associated with a lower rate of MACEs in patients with complex bifurcation lesions defined by the DEFINITION criterion. Graphical abstract

Bifurcation functional significance score as predictor of mortality: a validating study

Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the vessel and lesion, however, fail to give information about the functional significance of the bifurcation stenosis. To the best of our knowledge, there is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes. Patients with significant angiographic bifurcation lesions defined as diameter stenosis > 50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). 169 patients from Fiesta study (derivation cohort) and 555 patients from prospective bifurcation registry (clinical effect cohort) were analyzed to validate angiographic prediction score (BFSS) used to determine the potentially functional significance of coronary bifurcation stenosis. Bifurcation functional significance score (including the following parameters—SYNTAX ≥ 11, SB/MB BARI score, MV %DS ≥ 55%, main branch (MB) %DS ≥ 65%, lesion length ≥ 25 mm) with a maximum value of 11 was developed. A cut-off value of 6.0 was shown to give the best discriminatory ability—with accuracy 87% (sensitivity 77%, specificity 96%, p < 0.001). There was also a significant difference in all-cause mortality between patients with BFSS ≥ 6.0 vs. BFSS < 6.0–25.5% vs. 18.4%, log-rank p = 0.001 as well as cardiac mortality: BFSS ≥ 6.0 vs. BFSS < 6.0–17.7% vs. 14.5%, log-rank (p = 0.016). The cardiac mortality was significantly lower in patients with smaller absolute SB territory, p = 0.023. An angiographic score (BFSS) with good discriminatory ability to determine the functional significance of coronary bifurcation stenosis was developed. The value for BFSS ≥ 6.0 can be used as a discriminator to define groups with higher risk for all-cause and cardiac mortality. Also, we found that the smaller side branches pose greater mortality risk.

Real-Life Outcomes of Coronary Bifurcation Stenting in Acute Myocardial Infarction (Zabrze–Opole Registry)

Percutaneous coronary intervention (PCI) of bifurcation lesions is a technical challenge associated with high risk of adverse events, especially in primary PCI. The aim of the study is to analyze long-term outcomes after PCI for coronary bifurcation in acute myocardial infarction (AMI). The outcome was defined as the rate of major adverse cardiac event related to target lesion failure (MACE-TLF) (death-TLF, nonfatal myocardial infarction-TLF and target lesion revascularization (TLR)) and the rate of stent thrombosis (ST). From 306 patients enrolled to the registry, 113 were diagnosed with AMI. In the long term, AMI was not a risk factor for MACE-TLF. The risk of MACE-TLF was dependent on the culprit lesion, especially in the right coronary artery (RCA) and side branch (SB) with a diameter >3 mm. When PCI was performed in the SB, the inflation pressure in SB remained the single risk factor of poor prognosis. The rate of cumulative ST driven by late ST in AMI was dependent on the inflation pressure in the main branch (MB). In conclusion, PCI of bifurcation culprit lesions should be performed carefully in case of RCA and large SB diameter and attention should be paid to high inflation pressure in the SB. On the contrary, the lower the inflation pressure in the MB, the higher the risk of ST.

Comparative analysis of sequential pot-side-pot and kissing balloon techniques in patients with coronary bifurcation lesions treated with single stent strategy: propensity score analysis

Objectives It is unknown whether the novel re-POT technique is more effective than commonly preferred kissing balloon inflation (KBI) in patients with non-complex coronary bifurcation lesions (CBL) treated with single-stent strategy. Our aim was to compare the efficacy of re-POT and KBI techniques in one-stent strategy of non-complex CBL. Methods 283 patients were retrospectively analyzed (re-POT group, n=149; KBI group, n=134). Primary end-points of the study were defined as; in-hospital and 30-day mortality, contrast induced acute kidney injury (CI-AKI), stent thrombosis (ST), side branch (SB) dissection and need for SB stenting. Characteristics of patients at baseline were balanced by using propensity score inverse probability weighting (IPW). Results Procedure time (minute, 30.6±8.5 vs 34.3±11.6; p=0.003) and contrast volume (mL, 153.7±42.4 vs 171.1±58.2; p=0.004) were significantly lower in re-POT group. Besides, SB residual stenosis and number of patients with &gt;50% SB residual stenosis remained significantly higher in re-POT group both in general and true bifurcation subgroup analysis (20.3±19.8% vs 16.5±16.4%, p=0.02; 11.9% vs 5.7%, p=0.01 and 24.1±23.2% vs 18.8±18.7%, p=0.03; 17.6% vs 6.6%, p=0.005; respectively). Combined clinical adverse outcomes were similar between groups. (Figure 1) SB dissection (10.2% vs 20.1%, p=0.001) and need for SB stenting (12.6% vs 19%, p=0.04) were reached statistically significance in KBI group after adjustment. (Figure 2) Conclusions Re-POT may be a simple and safe technique with a shorter procedure time and lower incidence of adverse events in non-complex CBL treated with single-stent strategy. FUNDunding Acknowledgement Type of funding sources: None. Adverse clinical outcomes; weighted