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.

Coil Embolization for Coronary Artery Perforation: A Retrospective Analysis of 110 Patients

Objective. Coil embolization (CE) for coronary artery perforation (CAP) has not been thoroughly evaluated. This study aimed to evaluate the extent of myocardial damage and impact on cardiac function after CE for CAP. Methods. A total of 110 consecutive patients treated with CE for CAP were retrospectively identified. The degree of myocardial damage and impact on cardiac function were evaluated. Results. Forty-nine (44.5%) cases involved chronic total occlusions. A guidewire was the cause of perforation in 97 (88.2%) patients. The success rate of CE was 98.2%. Almost all patients were prescribed either antiplatelet drugs or anticoagulant medication or both. Patients with perforation types III and IV were found to be prone to creatinine kinase (CK) elevation and epicardial main vessel perforation, thereby causing myocardial damage. No changes were noted in the ejection fraction (EF) in patients with type V distal perforation and collateral channel perforation, while patients with perforation of the epicardial main vessel may show impaired cardiac function afterward. Conclusions. CE is safe and effective for treating CAP, especially when collateral channels and distal vessels are involved. Meanwhile, efforts should be taken to prevent CAP in epicardial main vessels since it may be difficult to treat with CS and cause myocardial damage when bailed out with CE leading to vessel sacrifice. We found that it was not necessary to change the anticoagulant regimen after CE owing to its ability to achieve robust hemostasis.

Where is the stent? CTA assists angiography: A case of jailed LAD

Stent malpositioning in the septal perforator is a serious procedural complication and especially prominent after main vessel stenting in coronary bifurcation lesions. This case report demonstrates Computed Tomography Angiography’s (CTA) role as a backup imaging tool, in cases where follow-up Coronary Angiogram (CAG) cannot be immediately completed. CTA also functions as a preferred imaging tool to follow up after stenting and assess for stent malpositioning. A 72-year-old female with history of hypertension and hyperlipidemia presented with dyspnea and was found to have STEMI. About a week after her three PCI’s to the Left Anterior Descending (LAD) artery, she returned to the hospital with recurrent dyspnea and V-Tach. Instead of completing a repeat catheterization, a noninvasive CTA was thought to be the next test. CTA imaging indicates that the failed stenting of the side-branch resulted in a jailed main vessel, which may induce ischemia and ventricular tachycardia (V-Tach). After the malpositioned stent finding on CTA, the patient was then referred to the Cath Lab for angiogram. CTA thus provided detailed anatomical information about the stent’s placement, which will greatly assist further management by the interventional cardiologist.

Bifurcation Functional Significance Score as Predictor of Mortality

Background: 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.Methods: 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 (test cohort) were analyzed to validate angiographic prediction score (BFSS) used to determine the potentially functional significance of coronary bifurcation stenosis.Results: Bifurcation functional significance score (including the following parameters - SYNTAX ≥11, SB/MB BARI score, MV %DS ≥ 55%, MB %DS ≥ 65%, lesion length ≥25mm) with a maximum value of 11 was developed. A cut-off value of 8.5 was shown to give the best discriminatory ability – with accuracy 87% (sensitivity 77%, specificity 96%, p<.001). There was also a significant difference in all-cause mortality between patients with BFSS≥8.5 vs. BFSS<8.5 – 17.8% vs. 13.4%, log-rank p=.006, as well as cardiac mortality: BFSS≥8.5 vs. BFSS<8.5 – 14.6% vs. 12.5%, log-rank (p=.042). The cardiac mortality was significantly lower in patients with smaller absolute SB territory, p=0.023.Conclusion: An angiographic score (BFSS) with good discriminatory ability to determine the functional significance of coronary bifurcation stenosis was developed. The value for BFSS≥8.5 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.

Differential Factors for Predicting Outcomes in Left Main versus Non-Left Main Coronary Bifurcation Stenting

Background: No large-scale study has compared the clinical and angiographic predictors of cardiovascular events in patients with left main bifurcation (LMB) and non-LMB stenting after second-generation DES implantation. Herein, we investigated differential clinical and angiographic factors for predicting outcomes in LMB versus non-LMB stenting. Methods: A total of 2648 patients with bifurcation lesions treated with second-generation DESs from the retrospective patient cohort were divided into an LMB group (n = 935) and a non-LMB group (n = 1713). The primary outcome was the 7-year incidence of target lesion failure (TLF), defined as the composite of cardiac death, myocardial infarction, and target lesion revascularization. Results: The incidence of TLF was 9.8%. Those in the LMB group were associated with a higher risk of TLF (14.2% versus 7.5%, p < 0.001) than those in the non-LMB group. Regarding the LMB group, independent predictors of TLF were chronic kidney disease (CKD), reduced left ventricular ejection fraction (LVEF), and two-stenting. Regarding the non-LMB group, CKD, reduced LVEF, old age, diabetes, and small diameter of the main vessel stent were independent predictors of TLF. Conclusions: The two-stent strategy could potentially increase TLF for the LMB lesions, and achieving the maximal diameter of the main vessel stent could result in better clinical outcomes for non-LMB lesions.

Ocean Wave Powered Boats

A brief outline of a feasibility study based on computer modeling of an ocean wave powered boat is presented. The boat consists of a main vessel hull and a trailing float with attached beams that are connected to the sides of the main vessel hull by revolute joints. The computer model is based on a Lagrangian formulation subject to the constraints of motion of the two bodies that a free to move radially about the revolute joints. Of special interest is the performance of the vessel-float system in moderate ocean conditions

Predictors and complications of side branch occlusion after recanalization of chronic total occlusions complicated with bifurcation lesions

Data on risk factors and periprocedural complications associated with side branch (SB) occlusion after chronic coronary total occlusion (CTO) recanalization are limited. The aims of this study were to identify independent predictors of side branch (SB) occlusion after chronic total occlusion (CTO) recanalization and assess the relationship between SB occlusion and perioperative complications. 245 patients with CTO bifurcation lesions (BFLs) who underwent successful CTO recanalization were included in the study. In the occlusion group, most of the SB occlusions were observed after the implantation of the stents and lack of SB protection was more common. However, there was no significant between-group difference in the angles between the main vessel (MV) and SB. SB occlusion was associated with a higher risk of periprocedural myocardial infarction and a higher composite periprocedural complication rate. Identified as predictors of SB occlusion were no SB protection, use of a dissection-reentry strategy, ostial SB stenosis, and proximal MV stenosis of 50% or more.

Inflation Pressure in Side Branch during Modified Jailed Balloon Technique Does Not Affect Side Branch Outcomes

Objectives. This study aimed to investigate the optimal jailed balloon inflation in the side branch during the modified jailed balloon technique for bifurcated lesions. Background. The modified jailed balloon technique is one of the effective techniques to minimize the emergence of side branch (SB) compromise by preventing plaque or carina shifting during a single stent strategy in the main vessel with provisional SB treatment. However, there are no detailed studies on the method of optimal jailed balloon inflation. Methods. We analyzed 51 consecutive patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions with a modified jailed balloon technique between September 2018 and December 2020. These 51 patients were divided into two groups according to the magnitude of inflation pressure of the jailed balloon: a higher pressure (HP) group and lower pressure (LP) group. Results. No significant differences in procedural outcomes were observed between the two groups. The findings of SB compromise were relatively common with our procedure (30.0% in the HP group; 33.3% in the LP group). The patterns of SB compromise such as dissection or stenosis increase were observed at similar frequencies between them. In particular, SB dissection was noted in the SB lesion with some plaque burden, irrespective of the magnitude of the jailed balloon inflation pressure. Univariate analysis showed that calcification in the main vessel and SB lesion length was significantly associated with SB compromise. Finally, all PCI procedures were successfully completed without any provisional stent deployment in SB. Conclusions. We speculate that lesion characteristics rather than the PCI procedural factors may be critical determinants to cause SB compromise.