At the bifurcation, the shear forces peak at the carina, creating areas of high endothelial shear stress.
The development of atherosclerosis in the LMCA has been linked to flow haemodynamics, with atherosclerotic plaques described at areas of low endothelial shear stress in the lateral wall of the bifurcation, opposite to the carina.
Conversely, the carina is often free from disease, probably owing to the protective effect of high shear stress against plaque formation.
The length of the LMCA also influences stenosis location and morphology. In short LMCA (<10 mm), lesions develop more frequently near the ostium than in the bifurcation (55% versus 38%), whereas in long arteries, lesions develop predominantly near the bifurcation (ostium 18% versus bifurcation 77%).
Furthermore, ostial lesions more frequently have negative remodelling, larger luminal areas, and less calcium than distal lesions.
Left main disease pci vs cabg excel trial 2016Kunal Mahajan
This randomized controlled trial compared percutaneous coronary intervention (PCI) using everolimus-eluting stents to coronary artery bypass grafting (CABG) for the treatment of left main coronary artery disease. The primary outcome was a composite of death, stroke, or myocardial infarction at 3 years. PCI was found to be non-inferior to CABG for the primary outcome. At 30 days, PCI had fewer adverse events like infections and bleeding, but more deaths, strokes and MIs. Between 30 days and 3 years, ischemia-driven revascularization was more common with PCI. Longer follow-up is still needed given differences in long-term medication use and revascularization between the treatments.
1) The document discusses management of left main coronary artery (LMCA) disease, including definitions, data on medical management versus revascularization, and techniques for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
2) Registry and randomized controlled trial data show that PCI and CABG have similar outcomes for LMCA disease, with PCI having higher rates of repeat revascularization.
3) Intravascular ultrasound and fractional flow reserve can help assess intermediate LMCA stenosis and optimize stent placement and outcomes. Achieving adequate stent expansion is important for bifurcation lesions.
This document discusses myocardial infarction with non-obstructive coronary arteries (MINOCA). Early coronary angiography identifies an occluded vessel in most patients with STEMI but in up to 10% of AMI patients, no vessel is occluded. These patients have MINOCA. The document outlines potential causes of MINOCA including coronary artery spasm, embolism, thrombophilia, and takotsubo cardiomyopathy. It provides diagnostic criteria for different causes and recommends diagnostic tests and treatments tailored to the identified cause. The prevalence of MINOCA among all MI cases is approximately 6% but ranges from 1-14%. Prognosis varies depending on the underlying cause.
Critical appraisal of Stitch Trial by Dr. Akshay Mehtacardiositeindia
The STICH trial tested two hypotheses regarding the treatment of ischemic heart failure:
1) Adding CABG to medical therapy improves long-term survival more than medical therapy alone.
2) For patients with anterior left ventricular dysfunction, surgical ventricular reconstruction plus CABG and medical therapy improves survival free of cardiac hospitalization more than CABG and medical therapy without ventricular reconstruction. The trial randomized over 1200 patients to test these hypotheses but did not find conclusive evidence to support either the primary or secondary hypotheses.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
The document discusses the history and evolution of bioabsorbable vascular scaffolds (BVS) as the potential fourth revolution in interventional cardiology. It describes the advantages of BVS over drug-eluting stents, including reduced risk of late stent thrombosis, restoration of vessel vasomotion and remodeling, and avoidance of long-term antiplatelet therapy. Various types of BVS are discussed, with the first implanted in humans constructed from poly-L-lactic acid that breaks down into lactic acid. Early clinical trials demonstrated comparable rates of restenosis to bare-metal stents.
Coronary bifurcation lesions are challenging to treat percutaneously and account for approximately 15% of PCIs. Interventions on bifurcations have lower success rates and higher complication rates than other lesions. The optimal strategy for treating bifurcations, whether provisional stenting of the main vessel with treatment of the side branch only if needed versus systematic two-stent techniques, is still debated. Several randomized trials have compared different approaches but longer-term data is still needed. Dedicated bifurcation stents may improve outcomes but need low profiles, ease of use, and cost effectiveness.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
Left main disease pci vs cabg excel trial 2016Kunal Mahajan
This randomized controlled trial compared percutaneous coronary intervention (PCI) using everolimus-eluting stents to coronary artery bypass grafting (CABG) for the treatment of left main coronary artery disease. The primary outcome was a composite of death, stroke, or myocardial infarction at 3 years. PCI was found to be non-inferior to CABG for the primary outcome. At 30 days, PCI had fewer adverse events like infections and bleeding, but more deaths, strokes and MIs. Between 30 days and 3 years, ischemia-driven revascularization was more common with PCI. Longer follow-up is still needed given differences in long-term medication use and revascularization between the treatments.
1) The document discusses management of left main coronary artery (LMCA) disease, including definitions, data on medical management versus revascularization, and techniques for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
2) Registry and randomized controlled trial data show that PCI and CABG have similar outcomes for LMCA disease, with PCI having higher rates of repeat revascularization.
3) Intravascular ultrasound and fractional flow reserve can help assess intermediate LMCA stenosis and optimize stent placement and outcomes. Achieving adequate stent expansion is important for bifurcation lesions.
This document discusses myocardial infarction with non-obstructive coronary arteries (MINOCA). Early coronary angiography identifies an occluded vessel in most patients with STEMI but in up to 10% of AMI patients, no vessel is occluded. These patients have MINOCA. The document outlines potential causes of MINOCA including coronary artery spasm, embolism, thrombophilia, and takotsubo cardiomyopathy. It provides diagnostic criteria for different causes and recommends diagnostic tests and treatments tailored to the identified cause. The prevalence of MINOCA among all MI cases is approximately 6% but ranges from 1-14%. Prognosis varies depending on the underlying cause.
Critical appraisal of Stitch Trial by Dr. Akshay Mehtacardiositeindia
The STICH trial tested two hypotheses regarding the treatment of ischemic heart failure:
1) Adding CABG to medical therapy improves long-term survival more than medical therapy alone.
2) For patients with anterior left ventricular dysfunction, surgical ventricular reconstruction plus CABG and medical therapy improves survival free of cardiac hospitalization more than CABG and medical therapy without ventricular reconstruction. The trial randomized over 1200 patients to test these hypotheses but did not find conclusive evidence to support either the primary or secondary hypotheses.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
The document discusses the history and evolution of bioabsorbable vascular scaffolds (BVS) as the potential fourth revolution in interventional cardiology. It describes the advantages of BVS over drug-eluting stents, including reduced risk of late stent thrombosis, restoration of vessel vasomotion and remodeling, and avoidance of long-term antiplatelet therapy. Various types of BVS are discussed, with the first implanted in humans constructed from poly-L-lactic acid that breaks down into lactic acid. Early clinical trials demonstrated comparable rates of restenosis to bare-metal stents.
Coronary bifurcation lesions are challenging to treat percutaneously and account for approximately 15% of PCIs. Interventions on bifurcations have lower success rates and higher complication rates than other lesions. The optimal strategy for treating bifurcations, whether provisional stenting of the main vessel with treatment of the side branch only if needed versus systematic two-stent techniques, is still debated. Several randomized trials have compared different approaches but longer-term data is still needed. Dedicated bifurcation stents may improve outcomes but need low profiles, ease of use, and cost effectiveness.
The document reports on a study from the ISCHEMIA trial investigating the impact of complete versus incomplete revascularization on clinical outcomes in patients with stable ischemic heart disease treated with an invasive versus conservative strategy. It finds that among patients treated with an invasive strategy, complete anatomic or functional revascularization was associated with improved outcomes compared to incomplete revascularization. However, after adjustment for covariates, the differences in outcomes between complete and incomplete revascularization were no longer statistically significant.
1) The DKCRUSH-V trial randomized 482 patients with true distal left main coronary artery bifurcation lesions to either double kissing (DK) crush stenting or provisional stenting (PS).
2) At 1-year follow-up, the primary endpoint of target lesion failure was lower in the DK crush group compared to the PS group.
3) At 3-year follow-up, target lesion failure rates remained lower in the DK crush group driven by lower rates of myocardial infarction and revascularization compared to the PS group. Definite or probable stent thrombosis was also lower in the DK crush group.
This document discusses chronic total occlusion (CTO) of coronary arteries. It defines CTO and differentiates it from functional occlusions and pseudo-occlusions. The prevalence of CTO is estimated to be around 15% based on registry data. CTOs present technical challenges for percutaneous coronary intervention (PCI) due to factors like lesion length, calcification, and tortuosity. Proper preparation is important for CTO PCI, including adequate guide support and anticoagulation. Scoring systems can help predict the difficulty of crossing a CTO. Special guidewires and techniques may be needed depending on the lesion characteristics and collateral pathways.
This document summarizes several clinical trials comparing on-pump coronary artery bypass grafting (CABG) to off-pump CABG. The CORONARY trial found no difference in mortality at 1 year between on and off-pump, but a slightly higher rate of revascularization with off-pump. The ROOBY trial found higher mortality at 5 years with off-pump compared to on-pump. The DOORS trial found better graft patency rates with on-pump (86%) than off-pump (76%). Trials like GOPCABE and SMART found similar outcomes between on and off-pump techniques. The PROMOTE trial found no significant difference in graft patency rates at 3 months between techniques
Fourth universal definition of myocardial infarction (2018)hospital
This document outlines the 2018 universal definition of myocardial infarction and describes its various types. It defines Type 1 MI as detected cardiac troponin rise with symptoms of ischemia. Type 3 MI occurs in patients who experience cardiac death before biomarkers can be obtained. Type 4a MI is elevation of troponin levels more than 5 times the cutoff 48 hours after percutaneous coronary intervention. Type 5 MI involves troponin elevation more than 10 times the cutoff 48 hours after coronary artery bypass grafting. It also describes myocardial infarction with non-obstructive coronary arteries.
- Left main coronary artery disease occurs in 5-7% of patients undergoing coronary angiography and is associated with high mortality if left untreated. The left main artery supplies a large portion of the heart.
- Left main disease can be caused by atherosclerosis, infections, inflammation, anomalies, or compression. Atherosclerosis particularly affects areas of low shear stress like the bifurcation.
- Percutaneous coronary intervention or coronary artery bypass grafting may be considered for treatment depending on the patient's characteristics and complexity of the disease. Outcomes are generally better when intravascular ultrasound is used to guide stenting of left main lesions. Patient selection is important to achieve good long-term results.
1) The document provides guidelines for coronary artery revascularization from the 2021 ACC/AHA/SCAI, including definitions of lesion severity, recommendations for revascularization of infarct arteries in STEMI, and timing of invasive strategies for NSTE-ACS.
2) It recommends using tools like the SYNTAX score and coronary physiology to help define lesion severity and guide revascularization decisions for intermediate lesions.
3) For STEMI patients, the guidelines recommend PCI if within 12 hours of symptoms or CABG if mechanical complications occur, and provide recommendations for revascularizing non-infarct arteries.
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
El ensayo clínico VICTORIA evaluó la eficacia y seguridad del vericiguat, un activador soluble de guanilato ciclasa, en pacientes con insuficiencia cardiaca y fracción de eyección reducida. Los resultados mostraron que el vericiguat redujo significativamente el objetivo primario combinado de muerte cardiovascular y hospitalizaciones por insuficiencia cardiaca en comparación con el placebo. Aunque no hubo una reducción estadísticamente significativa en la mortalidad cardiovascular, sí se observó una tendencia muy significativa. El tratamiento con ver
Carotid artery stenting – an update on atheroscleroticNeurologyKota
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis caused by atherosclerosis. The document provides recommendations for treatment of asymptomatic and symptomatic carotid stenosis. It summarizes data from trials comparing outcomes of carotid endarterectomy and stenting to medical management. The risks and benefits of carotid endarterectomy and stenting are discussed, along with indications, contraindications, procedural details, complications, and long-term outcomes of the procedures. Guidelines recommend carotid endarterectomy or stenting only when the risk of perioperative stroke and death is low (<6%).
This document discusses bifurcation lesions and various techniques for treating them. It begins by defining a bifurcation lesion and different types. It then discusses several classifications of bifurcation lesions including the Medina classification. It provides details on techniques such as T-stenting, crush stenting, culotte stenting and kissing balloon inflation. It summarizes several clinical trials that have compared outcomes of provisional side branch stenting versus systematic two-stent approaches. The document emphasizes that a provisional approach is generally preferred with side branch stenting only if needed. It provides guidance on wire and catheter selection, optimal techniques and the role of kissing balloon inflation.
This document provides guidance on percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs). It notes that PCI of native coronary arteries is preferred when feasible. For SVG PCI, it recommends the liberal use of embolic protection devices to reduce the risk of atheroembolism. It also provides tips for technical considerations like guide catheter selection and balloon inflation pressures. It discusses the indications for and results of SVG intervention in different time periods after CABG, noting higher risks for early reintervention but short-term benefits of PCI over reoperation.
Saphenous vein grafts used in coronary artery bypass grafting are prone to occlusion over time. Percutaneous interventions on occluded saphenous vein grafts carry risks of distal embolization. Techniques to reduce this risk include use of embolic protection devices, which filter out debris, and proximal occlusion devices, which block blood flow during the intervention. Drug-eluting stents may reduce restenosis compared to bare-metal stents in saphenous vein grafts, but dual antiplatelet therapy is required. While percutaneous interventions on saphenous vein grafts can relieve symptoms, the underlying disease progression remains an issue.
This document discusses in-stent neoatherosclerosis, which refers to the development of new atherosclerotic lesions inside coronary stents. Percutaneous coronary intervention procedures like stenting cause endothelial injury and disrupt blood flow, promoting inflammation and accelerated atherosclerosis. Over time, this can lead to problems like in-stent restenosis and late stent thrombosis. While similar to native coronary atherosclerosis, in-stent neoatherosclerosis develops more rapidly. Factors like stent strut design, polymer coatings, and incomplete re-endothelialization all contribute to this pathological process.
The document discusses various stenting strategies for treating coronary bifurcation lesions, including newer advancements. It summarizes findings on stent thrombosis and major adverse cardiac event rates from randomized trials comparing one-stent versus two-stent approaches. It also outlines techniques for provisional stenting, elective double stenting, crush and sleeve methods, and left main coronary artery bifurcation stenting. Potential issues and solutions with crush techniques are described.
This document summarizes several key trials that evaluated percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease. The COURAGE and BARI 2D trials found no difference in mortality or cardiovascular outcomes between PCI plus OMT versus OMT alone. The FAME 2 trial found lower rates of urgent revascularization with FFR-guided PCI plus OMT versus OMT alone. Overall, OMT should be the first-line treatment for stable angina, with PCI reserved for refractory angina or markedly positive stress tests. More research is still needed to define the role of PCI versus OMT.
This document discusses restenosis (renarrowing of arteries) after percutaneous coronary intervention (PCI) procedures like balloon angioplasty and stent placement. It notes that drug-eluting stents have significantly reduced restenosis rates compared to bare metal stents. However, in-stent restenosis remains a problem, occurring in approximately 5-7% of patients within 1-2 years after PCI. The document examines factors that can influence restenosis risk like patient characteristics, lesion characteristics, technical aspects of the procedure, and properties of the stents. It also discusses challenges in treating in-stent restenosis when it does occur.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Coronary artery ectasia (CAE) is an inappropriate dilatation of the coronary arteries. It has an unknown etiology but may be due to genetic or inflammatory factors. CAE is detected in 3-8% of angiograms and can be diffuse or localized. It can cause angina due to turbulent blood flow. Diagnosis is typically made using angiography, CT, or MRI imaging. Treatment involves aspirin due to risk of thrombosis, with surgical revascularization for significant coronary artery disease.
The study investigated the incidence and risk factors of venous obstruction before and after implantation of transvenous pacing leads in 131 patients using digital subtraction angiography (DSA). DSA was performed before implantation and at 44 months follow-up in 79 patients. Prior to implantation, venous obstruction was found in 18 patients (13.7%), mainly in the left innominate vein. After implantation, venous obstruction occurred in 26 of 79 patients (32.9%) at follow-up DSA. There were no significant differences in risk factors between patients with or without obstruction. The incidence of obstruction after implantation was lower than previous reports, possibly due to pre-existing obstruction being identified prior to implantation.
1) The DKCRUSH-V trial randomized 482 patients with true distal left main coronary artery bifurcation lesions to either double kissing (DK) crush stenting or provisional stenting (PS).
2) At 1-year follow-up, the primary endpoint of target lesion failure was lower in the DK crush group compared to the PS group.
3) At 3-year follow-up, target lesion failure rates remained lower in the DK crush group driven by lower rates of myocardial infarction and revascularization compared to the PS group. Definite or probable stent thrombosis was also lower in the DK crush group.
This document discusses chronic total occlusion (CTO) of coronary arteries. It defines CTO and differentiates it from functional occlusions and pseudo-occlusions. The prevalence of CTO is estimated to be around 15% based on registry data. CTOs present technical challenges for percutaneous coronary intervention (PCI) due to factors like lesion length, calcification, and tortuosity. Proper preparation is important for CTO PCI, including adequate guide support and anticoagulation. Scoring systems can help predict the difficulty of crossing a CTO. Special guidewires and techniques may be needed depending on the lesion characteristics and collateral pathways.
This document summarizes several clinical trials comparing on-pump coronary artery bypass grafting (CABG) to off-pump CABG. The CORONARY trial found no difference in mortality at 1 year between on and off-pump, but a slightly higher rate of revascularization with off-pump. The ROOBY trial found higher mortality at 5 years with off-pump compared to on-pump. The DOORS trial found better graft patency rates with on-pump (86%) than off-pump (76%). Trials like GOPCABE and SMART found similar outcomes between on and off-pump techniques. The PROMOTE trial found no significant difference in graft patency rates at 3 months between techniques
Fourth universal definition of myocardial infarction (2018)hospital
This document outlines the 2018 universal definition of myocardial infarction and describes its various types. It defines Type 1 MI as detected cardiac troponin rise with symptoms of ischemia. Type 3 MI occurs in patients who experience cardiac death before biomarkers can be obtained. Type 4a MI is elevation of troponin levels more than 5 times the cutoff 48 hours after percutaneous coronary intervention. Type 5 MI involves troponin elevation more than 10 times the cutoff 48 hours after coronary artery bypass grafting. It also describes myocardial infarction with non-obstructive coronary arteries.
- Left main coronary artery disease occurs in 5-7% of patients undergoing coronary angiography and is associated with high mortality if left untreated. The left main artery supplies a large portion of the heart.
- Left main disease can be caused by atherosclerosis, infections, inflammation, anomalies, or compression. Atherosclerosis particularly affects areas of low shear stress like the bifurcation.
- Percutaneous coronary intervention or coronary artery bypass grafting may be considered for treatment depending on the patient's characteristics and complexity of the disease. Outcomes are generally better when intravascular ultrasound is used to guide stenting of left main lesions. Patient selection is important to achieve good long-term results.
1) The document provides guidelines for coronary artery revascularization from the 2021 ACC/AHA/SCAI, including definitions of lesion severity, recommendations for revascularization of infarct arteries in STEMI, and timing of invasive strategies for NSTE-ACS.
2) It recommends using tools like the SYNTAX score and coronary physiology to help define lesion severity and guide revascularization decisions for intermediate lesions.
3) For STEMI patients, the guidelines recommend PCI if within 12 hours of symptoms or CABG if mechanical complications occur, and provide recommendations for revascularizing non-infarct arteries.
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
El ensayo clínico VICTORIA evaluó la eficacia y seguridad del vericiguat, un activador soluble de guanilato ciclasa, en pacientes con insuficiencia cardiaca y fracción de eyección reducida. Los resultados mostraron que el vericiguat redujo significativamente el objetivo primario combinado de muerte cardiovascular y hospitalizaciones por insuficiencia cardiaca en comparación con el placebo. Aunque no hubo una reducción estadísticamente significativa en la mortalidad cardiovascular, sí se observó una tendencia muy significativa. El tratamiento con ver
Carotid artery stenting – an update on atheroscleroticNeurologyKota
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis caused by atherosclerosis. The document provides recommendations for treatment of asymptomatic and symptomatic carotid stenosis. It summarizes data from trials comparing outcomes of carotid endarterectomy and stenting to medical management. The risks and benefits of carotid endarterectomy and stenting are discussed, along with indications, contraindications, procedural details, complications, and long-term outcomes of the procedures. Guidelines recommend carotid endarterectomy or stenting only when the risk of perioperative stroke and death is low (<6%).
This document discusses bifurcation lesions and various techniques for treating them. It begins by defining a bifurcation lesion and different types. It then discusses several classifications of bifurcation lesions including the Medina classification. It provides details on techniques such as T-stenting, crush stenting, culotte stenting and kissing balloon inflation. It summarizes several clinical trials that have compared outcomes of provisional side branch stenting versus systematic two-stent approaches. The document emphasizes that a provisional approach is generally preferred with side branch stenting only if needed. It provides guidance on wire and catheter selection, optimal techniques and the role of kissing balloon inflation.
This document provides guidance on percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs). It notes that PCI of native coronary arteries is preferred when feasible. For SVG PCI, it recommends the liberal use of embolic protection devices to reduce the risk of atheroembolism. It also provides tips for technical considerations like guide catheter selection and balloon inflation pressures. It discusses the indications for and results of SVG intervention in different time periods after CABG, noting higher risks for early reintervention but short-term benefits of PCI over reoperation.
Saphenous vein grafts used in coronary artery bypass grafting are prone to occlusion over time. Percutaneous interventions on occluded saphenous vein grafts carry risks of distal embolization. Techniques to reduce this risk include use of embolic protection devices, which filter out debris, and proximal occlusion devices, which block blood flow during the intervention. Drug-eluting stents may reduce restenosis compared to bare-metal stents in saphenous vein grafts, but dual antiplatelet therapy is required. While percutaneous interventions on saphenous vein grafts can relieve symptoms, the underlying disease progression remains an issue.
This document discusses in-stent neoatherosclerosis, which refers to the development of new atherosclerotic lesions inside coronary stents. Percutaneous coronary intervention procedures like stenting cause endothelial injury and disrupt blood flow, promoting inflammation and accelerated atherosclerosis. Over time, this can lead to problems like in-stent restenosis and late stent thrombosis. While similar to native coronary atherosclerosis, in-stent neoatherosclerosis develops more rapidly. Factors like stent strut design, polymer coatings, and incomplete re-endothelialization all contribute to this pathological process.
The document discusses various stenting strategies for treating coronary bifurcation lesions, including newer advancements. It summarizes findings on stent thrombosis and major adverse cardiac event rates from randomized trials comparing one-stent versus two-stent approaches. It also outlines techniques for provisional stenting, elective double stenting, crush and sleeve methods, and left main coronary artery bifurcation stenting. Potential issues and solutions with crush techniques are described.
This document summarizes several key trials that evaluated percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease. The COURAGE and BARI 2D trials found no difference in mortality or cardiovascular outcomes between PCI plus OMT versus OMT alone. The FAME 2 trial found lower rates of urgent revascularization with FFR-guided PCI plus OMT versus OMT alone. Overall, OMT should be the first-line treatment for stable angina, with PCI reserved for refractory angina or markedly positive stress tests. More research is still needed to define the role of PCI versus OMT.
This document discusses restenosis (renarrowing of arteries) after percutaneous coronary intervention (PCI) procedures like balloon angioplasty and stent placement. It notes that drug-eluting stents have significantly reduced restenosis rates compared to bare metal stents. However, in-stent restenosis remains a problem, occurring in approximately 5-7% of patients within 1-2 years after PCI. The document examines factors that can influence restenosis risk like patient characteristics, lesion characteristics, technical aspects of the procedure, and properties of the stents. It also discusses challenges in treating in-stent restenosis when it does occur.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Coronary artery ectasia (CAE) is an inappropriate dilatation of the coronary arteries. It has an unknown etiology but may be due to genetic or inflammatory factors. CAE is detected in 3-8% of angiograms and can be diffuse or localized. It can cause angina due to turbulent blood flow. Diagnosis is typically made using angiography, CT, or MRI imaging. Treatment involves aspirin due to risk of thrombosis, with surgical revascularization for significant coronary artery disease.
The study investigated the incidence and risk factors of venous obstruction before and after implantation of transvenous pacing leads in 131 patients using digital subtraction angiography (DSA). DSA was performed before implantation and at 44 months follow-up in 79 patients. Prior to implantation, venous obstruction was found in 18 patients (13.7%), mainly in the left innominate vein. After implantation, venous obstruction occurred in 26 of 79 patients (32.9%) at follow-up DSA. There were no significant differences in risk factors between patients with or without obstruction. The incidence of obstruction after implantation was lower than previous reports, possibly due to pre-existing obstruction being identified prior to implantation.
96091164 Slice Ct And Cerebral Atherosclerosis02calaf0618
1. Carotid endarterectomy reduces the risk of stroke compared to medical therapy alone in patients with symptomatic moderate (50-69%) carotid stenosis, with an absolute risk reduction of about 5-10% over 5 years.
2. For asymptomatic carotid stenosis ≥60%, carotid endarterectomy provides a relative risk reduction of 53% compared to aspirin alone, but medical therapy is still usually recommended due to the low baseline risk.
3. Carotid artery stenting is recommended for patients who are not suitable for surgery due to high surgical risk from conditions like severe cardiac or pulmonary disease.
The document describes the anatomy of the carotid arteries and their branches, evaluation and imaging of carotid artery disease, and treatment strategies including lifestyle modifications to reduce risk factors, carotid endarterectomy to remove plaques from significantly stenotic arteries, and outcomes data from clinical trials on endarterectomy for symptomatic and asymptomatic carotid stenosis. Imaging modalities like carotid duplex ultrasound, CTA, and MRA are described for evaluating the degree of carotid stenosis. The benefits of carotid endarterectomy are greater for symptomatic high-grade stenosis while more moderate for asymptomatic disease.
Carotid artery stenosis refers to atherosclerotic narrowing of the carotid arteries. While a correlation between stenosis level and stroke risk is expected, the relationship is unclear. Carotid artery stenosis is variably defined as 60-99% or 50-99% narrowing. Screening for carotid artery stenosis can be done with neck auscultation or ultrasound, but both have limitations in sensitivity and specificity compared to angiography. Noninvasive imaging techniques like ultrasound and MRI are better options for screening and diagnosis of carotid artery stenosis.
This document summarizes the diagnosis and management of local complications associated with transradial access for coronary procedures. It discusses radial artery occlusion, hand ischemia, radial artery spasm, forearm hematoma, compartment syndrome, catheter entrapment, pseudoaneurysm, and arteriovenous fistula. Predictors and treatments for various complications are provided. The incidence of radial artery occlusion can range from 0.8-30% depending on the time and method of assessment. Hand ischemia due to radial artery occlusion is rare but can occur in systemically unwell patients with prolonged radial cannulation. Radial artery spasm is common and treatments include antispasmodic medications and adequate analgesia/sedation.
This review article discusses aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). It notes that AR is more common after TAVI than surgical aortic valve replacement, with mild AR observed in about 70% of TAVI patients. Even mild AR has been linked to decreased survival up to two years after the procedure. The review aims to provide an overview of the three types of AR that can occur after TAVI - transvalvular, paravalvular, and supraskirtal - focusing on their different pathophysiological mechanisms. Accurate evaluation and classification of AR is important for understanding its implications, but challenging due to limitations of echocardiography for assessing transcatheter
This document discusses left main coronary artery (LMCA) percutaneous coronary intervention (PCI). Key points:
1. LMCA disease can be treated with balloon angioplasty or stenting. Drug-eluting stents have reduced restenosis rates compared to bare-metal stents.
2. Assessment of LMCA lesions includes angiography as well as intravascular ultrasound (IVUS) and fractional flow reserve (FFR) to determine significance. An IVUS minimum luminal area <4.5mm2 or FFR<0.80 indicate a significant stenosis.
3. Techniques for stenting LMCA lesions depend on location and involve strategies like single crossover stenting or provisional two
extracranial and intracranial cerebral collateral circulation .pptxDr.Ahmed M Khalaf
Collaterals between intracranial and extracranial circulation
leptomeningeal anastomosis
circle of wills
acute stroke
venous collateral circulation
primary secondary tertiary collaterals
orbital plexus
tectal plexus
IMAGING METHODS TO ASSESS THE STRUCTURE OF COLLATERALS
ct angiography
CTA
MRA
transcranial doppler TCD
Augmentation of cerebral blood flow in acute stroke
pathophysiology
Acs0611 Repair Of Infrarenal Abdominal Aortic Aneurysmsmedbookonline
This document provides information on repair of infrarenal abdominal aortic aneurysms. It defines an arterial aneurysm and describes the most common cause as atherosclerotic degeneration of the arterial wall. For infrarenal abdominal aortic aneurysms, preoperative evaluation assesses risk factors and confirms diagnosis and aneurysm size using imaging such as duplex ultrasonography, computed tomography, or magnetic resonance imaging. Open surgical repair involves an abdominal incision, aortic clamping and graft placement to exclude the aneurysm from circulation. Patient selection considers aneurysm size and symptoms as well as surgical risk factors.
This document discusses carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for treatment of carotid artery stenosis. It provides details on patient selection criteria and describes the CAS procedure, including diagnostic arteriography, embolic protection device placement, stent placement, and post-procedure care. Several major clinical trials are summarized that demonstrated CAS to be non-inferior to CEA for reducing risk of stroke in both symptomatic and asymptomatic patients.
This document discusses carotid artery stenting as an alternative to carotid endarterectomy for treating carotid artery stenosis. It provides details on:
1) Clinical trials that have established carotid stenting as an equivalent option to carotid endarterectomy for reducing risk of stroke, with some trials finding stenting superior for certain patient groups.
2) Guidelines from organizations like the ACC/AHA that recommend carotid stenting as a Class I or IIa option for symptomatic and select asymptomatic patients.
3) The procedure of carotid artery stenting, including patient preparation, diagnostic arteriogram, techniques for embolic protection and stent placement.
Carotid revascularization in cad patientsDIPAK PATADE
Carotid artery disease is common in patients with coronary artery disease undergoing coronary artery bypass grafting (CABG). The incidence of perioperative stroke after CABG is around 1.6-3.1%, with risks increased by factors like aortic atherosclerosis, atrial fibrillation, prior stroke, and carotid stenosis. Strokes are often embolic and occur during or soon after surgery. Asymptomatic carotid stenosis alone may not increase stroke risks significantly, but bilateral or recently symptomatic stenosis does. Careful screening and management of atherosclerotic risk factors can help reduce perioperative stroke risks in patients with coexisting carotid and coronary artery disease.
Cardiac CT Angiography to detect Myocardial Bridging Han Naung Tun
CTCA is a reliable non-invasive tool for detecting myocardial bridging in coronary artery disease. [The study] found an 8.2% frequency of myocardial bridging in 219 patients with coronary artery disease who underwent CTCA. CTCA allows for visualization of the length and depth of the bridging artery and measurement of stenosis. While myocardial bridging can be clinically significant when associated with hemodynamic changes, in most cases it remains asymptomatic. CTCA is an emerging alternative to other invasive tests for diagnosing myocardial bridging.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
Evaluation of Occlusive Diseases in Cervical Arteries in Patients of Acute Is...QUESTJOURNAL
This document summarizes a study that evaluated occlusive diseases in cervical arteries of patients with acute ischemic stroke using CT angiography. The study analyzed CTA images of 50 patients to determine the percentage with vascular stenosis or occlusion. It found that 76% of patients showed neck vessel involvement, with 26% having luminal narrowing and 8% having complete occlusion. While many vessels showed atherosclerotic changes, only 45 of 300 total vessels analyzed showed significant luminal narrowing or plaque formation. The study concludes there is a significant correlation between atherosclerotic changes in neck vessels and occurrence of acute ischemic stroke.
The document discusses current management and future challenges in treating mitral valve disease, specifically focusing on primary mitral regurgitation, secondary mitral regurgitation, and mitral stenosis due to annular calcification.
For primary mitral regurgitation, surgical repair is the standard of care for symptomatic patients or those with left ventricular dysfunction. New transcatheter mitral valve repair options like the MitraClip are also producing good outcomes in high-risk surgical patients. Clinical trials are underway to evaluate transcatheter options versus surgery for intermediate risk patients.
The management of secondary mitral regurgitation, caused by left ventricular issues, is less clear. Outcomes from ongoing clinical trials of new treatments will help
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
The document describes the development and use of the SYNTAX score, which is a tool used to grade the anatomical complexity of a patient's coronary artery disease. The SYNTAX score was created based on several existing scoring systems and aims to provide a detailed assessment of each lesion through a series of questions. It evaluates factors like the number and location of lesions, collateral connections, and characteristics like length, calcification, and thrombus formation. A separate score is calculated for each lesion and summed to provide the total SYNTAX score, which correlates with long-term outcomes of coronary artery bypass grafting. While it is useful for predicting outcomes, the score does not consider clinical factors and its assessment relies on subjective evaluation.
Similar to LMCA : Evolution of management GABG to PCI (20)
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Cardiac troponin (cTn) elevation is a common finding in acutely admitted patients, even in the absence of acute coronary syndrome. In some of these patients, no etiology of cTn elevation can be identified. The term troponinemia is sometimes used to describe this scenario.
The proportion of patients discharged from the emergency department without a specified diagnosis but with cTn levels above the 99th percentile has been reported as 31%.
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions
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The categorization of patients based on the PRECISE-DAPT score was shown to be useful to inform decision-making for duration of DAPT in stented patients
Acute myocardial infarction (MI) typically occurs from a plaque rupture or erosion within a coronary artery,known as the infarct-related artery (IRA)
In patients with NSTEMI compared with those with ST-segment–elevation MI, identification of the IRA can be challenging because patients are more likely to present with either multivessel coronary artery disease (CAD) or insignificant CAD
Coronary artery calcification (CAC) results in reduced vascular compliance, abnormal vasomotor responses, and impaired myocardial perfusion.
The presence of CAC is associated with worse outcomes in the general population and in patients undergoing revascularization
Two recognized types of CAC are
Atherosclerotic (Intimal)
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Conduction system abnormalities after transcatheter aortic valve replacement ...NAJEEB ULLAH SOFI
Aortic stenosis (AS) is a common form of valvular heart disease, the global burden of which continues to increase.
Untreated, severe symptomatic AS carries a high mortality rate.
Initially performed in patients deemed unsuitable for surgery, and then advancing to become an option for patients with high, intermediate, and now low operative risk, TAVR has revolutionized the treatment of symptomatic severe AS .
TAVR is noninferior to surgical aortic valve replacement (SAVR) with regard to mortality at 1 year
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As a result, from a single imaging session, one could obtain a wealth of information regarding
cardiac function and morphology,
myocardial perfusion & viability,
hemodynamics,
large vessel anatomy.
CMR is now considered the gold standard for the assessment of regional and global systolic function, myocardial infarction (MI) and viability, and the assessment of congenital heart disease.
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CCM signals are non-excitatory electrical signals applied during the cardiac absolute refractory period that enhance the strength of cardiac muscular contraction
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InStent Resetenosis: An Algorithmic Approach to Diagnosis and TreatmentNAJEEB ULLAH SOFI
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The cumulative rates of DES failure have created a major clinical problem so that > 10% of all PCIs done in the United States are to treat ISR, and the number of ISR interventions appears to be increasing year over year
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2. For stable coronary artery disease, preoperative revascularization through PCI or CABG is generally not recommended as studies found no reduction in adverse cardiac events. Indications for preoperative angiography include extensive ischemia on testing or severe angina.
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PAD can be diagnosed in asymptomatic individuals by a combination of physical examination and simple, noninvasive Doppler ultrasonography to measure the ankle–brachial index
New Heart Failure modalities: HIS Bundle Pacing & Cardiac Contractility Modul...NAJEEB ULLAH SOFI
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Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
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Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
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NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
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“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
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3. The left main coronary artery provides 84% of the blood flow to the left
ventricle in patients with right dominant coronary circulation.
Left main coronary artery disease accounts for 4–9% of patients referred for
coronary angiography.
In historical studies, 3-year mortality in patients with unprotected left main
coronary artery disease receiving only medical therapy (mainly nitrate and a β-
blocker) was nearly 50%.
4. Anatomy and pathophysiology
The left main coronary artery has an average length of 10 mm (2–23 mm), with
a mean diameter of 3.9 ± 0.4 mm in women and 4.5 ± 0.5 mm in men.
Divided into three parts: ostium, shaft, and distal segment.
The ostium lacks an adventitia layer, has abundant smooth muscle cells, and
has the most elastic tissue of the coronary vessels; these histological features
might account for a particular response (for example, higher elastic recoil) to
PCI at this location. The shaft and distal segments have a trilayered
architecture (with intima, media, and adventitia), which is similar to other
epicardial vessels.
LMCA blood flow peaks in diastole, reaching approximately 200 ml/min/100 g
at a velocity of 40–60 cm/s
5. At the bifurcation, the shear forces peak at the carina, creating areas of high
endothelial shear stress.
The development of atherosclerosis in the LMCA has been linked to flow
haemodynamics, with atherosclerotic plaques described at areas of low
endothelial shear stress in the lateral wall of the bifurcation, opposite to the
carina.
Conversely, the carina is often free from disease, probably owing to the
protective effect of high shear stress against plaque formation.
The length of the LMCA also influences stenosis location and morphology. In
short LMCA (<10 mm), lesions develop more frequently near the ostium than
in the bifurcation (55% versus 38%), whereas in long arteries, lesions develop
predominantly near the bifurcation (ostium 18% versus bifurcation 77%).
Furthermore, ostial lesions more frequently have negative remodelling, larger
luminal areas, and less calcium than distal lesions.
8. Anatomical assessment
A diameter stenosis of 50% has been historically used as the threshold for
considering revascularization.
A negative correlation between visual diameter stenosis of unprotected LMCA,
measured with coronary angiography as a continuous metric, and survival has
been reported.
Patients with diameter stenosis between 50% and 70% had significantly higher
survival than those with diameter stenosis > 70%.
Angiography tends to underestimate the severity of left main coronary artery
disease
Hermiller et al. showed that 89% of patients with an angiographically normal
left main coronary artery had some degree of disease when assessed by IVUS.
Detailed anatomical or functional evaluation is warranted, particularly in cases
of intermediate diameter stenosis (40–70%).
9. Using FFR as the reference standard (FFR ≤ 0.75), Jasti et al. proposed an
IVUS MLA threshold of 5.9 mm2 for predicting physiological significance. A
similar comparison (IVUS versus FFR) in an Asian population yielded a lower
IVUS MLA cut- off of 4.5 mm2.
The LITRO study prospectively validated an IVUS- derived MLA cut- off of 6
mm2 for deferral of revascularization in patients with unprotected LMCA
disease. At 2 years, MACE rates and cardiac death- free survival were similar in
patients who were deferred (MLA ≥ 6 mm2) and those who underwent
revascularization (MLA < 6 mm2).
The disagreement between angiography and this IVUS criterion for a
significant stenosis was substantial. One third of patients with an insignificant
angiographic stenosis of <30% had an MLA of <6 mm2, whereas 43% of
patients with angiographic LM stenosis ≥50% had a prognostically favorable
MLA of ≥6 mm.
10. IVUS is a better tool for determining the anatomical extent of disease, FFR is
a better tool for assessing the hemodynamically significance of an LM stenosis.
FFR may be limited by the frequent presence of significant downstream
stenoses, which may underestimate or overestimate the hemodynamic
significance of the LM lesion.
However, this is of more concern when there is severe disease present in both
the left anterior descending and circumflex arteries.
11. Fearon et al showed that when only one major branch of the left main has
severe disease, downstream disease does not have a clinically relevant impact
on the evaluation of intermediate LM stenosis with the pressure wire placed in
the nondiseased branch.
Based on their findings, if the FFR of the LM is either ≤0.80 or >0.85, then it
can be assumed that the LM lesion is hemodynamically significant or
insignificant, respectively.
However, if the FFR is between 0.81 and 0.85, then the hemodynamic
significance of the LM lesion cannot be accurately determined if the combined
FFR of the LM and the downstream disease is ≤0.45. In such situations, IVUS
guidance is preferred
12. Coronary CT angiography. Noninvasive coronary CT angiography (CCTA) has
been recommended as the first- line diagnostic test for patients with suspected
coronary artery disease.
The presence of atherosclerotic disease irrespective of the luminal obstruction
was associated with worse prognosis.
CCTA can accurately identify patients with in- stent restenosis, even with
metallic stents
FFR derived from coronary CT angiography. Blood- flow simulation using
patient- specific coronary geometries has recently been introduced into clinical
practice. The FFR derived from CCTA (FFRCT; HeartFlow, USA) has been
shown to have high diagnostic accuracy with invasive FFR as a reference
13. 1 . O P T I M A L M E D I C A L T H E R A P Y
2 . P C I
3 . CA B G
TREATMENT
14. A meta- analysis of the early studies showed that patients with
unprotected left main coronary artery disease had the greatest
survival benefit with surgical revascularization (OR 0.32, 95% CI
0.15–0.70, P = 0.0004), establishing CABG surgery as the
treatment of choice for these patients.
In 1977, Andreas Grüntzig successfully attempted the first balloon angioplasty
for unprotected left main coronary artery disease; however, he subsequently
reported in 1979 that balloon angioplasty was not suitable for unprotected left
main coronary artery disease.
The first series of studies showed that balloon angioplasty for unprotected left
main coronary artery disease was feasible in 94% of patients. However, a
periprocedural mortality of 9.1% and a survival of 36.0 % at 3 years was
prohibitive.
15. The advent of bare- metal stents revived interest in PCI for unprotected left
main coronary artery disease, but the high restenosis rates with bare- metal
stents limited the use of the procedure to patients at high surgical risk.
The development of drug- eluting stents (DESs) has markedly improved the
prognosis after PCI in patients with unprotected left main coronary artery
disease, with randomized trials demonstrating a similar survival with PCI and
CABG surgery at mid- term follow-up.
16. PCI vs CABG
A number of risk score systems have been proposed over the years to guide
decision- making between PCI or CABG surgery in patients with unprotected
left main coronary artery disease, including anatomical, clinical, combined
(anatomic and clinical), and functional risk scores
The SYNTAX score, which is based entirely on anatomical
characteristics (that is, bifurcation lesions, lesion length, severe calcification,
tortuosity, and thrombus), defines three categories of risk (low, intermediate,
and high) based on conventional thresholds (≤ 22, 23–32, and ≥ 33,
respectively)
The SYNTAX score II incorporates not only anatomical but also clinical
variables (age, sex, left ventricular ejection fraction, serum creatinine
clearance, presence of left main coronary artery disease, peripheral vascular
disease, and chronic obstructive pulmonary disease plus the anatomical
SYNTAX score) into logistic formulas for estimating 4-year mortality after PCI
and CABG surgery
17. RCT Registry
LE MANS
Boudriot
PRECOMBAT
SYNTAX
EXCEL
NOBLE
IRIS-MAIN (Asia)
MAIN-COMPARE
(Korean)
Left Main RCTs of PCI vs CABG
23. Background
SYNTAX trial was a non-inferiority trial that compared
PCI using first-generation paclitaxel-eluting stents with
CABG in patients with de-novo three-vessel and left
main CAD, and reported results up to 5 years
SYNTAXES trial examined all-cause death after 10
years of follow-up in patients randomly assigned to
PCI or CABG
24. Methods
SYNTAX Extended Survival (SYNTAXES) study is an
investigator-driven extension of follow-up of a multicentre, RCT
done in 85 hospitals across 18 North American and European
countries.
Patients with de-novo three-vessel and left main CAD were
randomly assigned (1:1) to the PCI group or CABG group.
Prespecified subgroup analyses were performed according to
the presence or absence of LMCA disease and Diabetes, and
according to coronary complexity defined by core laboratory
SYNTAX score tertiles
25. Data Primary End Point
From March, 2005, to April,
2007, 1800 patients were
randomly assigned to the PCI
(n=903) or CABG (n=897) group.
Vital status information at 10
years was complete for 841
(93%) patients in the PCI group
and 848 (95%) patients in the
CABG group.
10-year all-cause
death
26. Results
At 10 years, 244 (27%) patients had died after PCI and 211
(24%) after CABG (hazard ratio 1·17 [95% CI 0·97-1·41],
p=0·092)
Among patients with TVD , 151 (28%) of 546 had died after PCI
versus 113 (21%) of 549 after CABG (hazard ratio 1·41 [95% CI
1·10-1·80])
Among patients with LMCA Ds, 93 (26%) of 357 had died
after PCI versus 98 (28%) of 348 after CABG (0·90 [0·68-1·20],
pinteraction=0·019)
29. Kaplan-Meier curves for 10-year all-cause death in prespecified
SYNTAX score tertile subgroups
30. Forest plot of prespecified subgroup analyses of 10-year
all-cause death
31. Conclusion
At 10 years, no significant difference existed in all-
cause death between PCI using first-generation
paclitaxel-eluting stents and CABG
However, CABG provided a significant survival
benefit in patients with three-vessel disease, but
not in patients with LMCA Ds.
32. A P R O SP E C T I VE , R A N D O M I ZE D T R I A L
C O M P A R I N G E VE R O L I M U S - E L U T I N G ST E N T S
A N D B Y P A SS G R A F T SU R G E R Y I N SE L E C T E D
P A T I E N T S W I T H L E F T M A I N C O R O N A R Y
A R T E R Y D I SE A SE
FIVE-YEAR OUTCOME
EXCEL trial
33. Background Trial Design
• Subset analysis from the SYNTAX
trial suggested that DES may be an
acceptable option for pts with
LMCAD and low or moderate CAD
complexity
• Since SYNTAX, PCI and surgical
outcomes have both improved,
necessitating a contemporary trial
examining revascularization
alternatives in LMCAD
The EXCEL trial included 1,905
patients with unprotected LMCA
disease with low or intermediate
SYNTAX scores randomly assigned
to PCI with contemporary
everolimus- eluting stents or to
CABG surgery.
Primary outcome was
a composite of death, stroke,
or myocardial infarction
34. R
Follow-up: 1 month, 6 months, 1 year, annually through 5 years
Primary endpoint: Measured at a median 3-yr FU, minimum 2-yr FU
Study Design
2900 pts with unprotected left main disease
SYNTAX score ≤32
Consensus agreement of eligibility and equipoise by heart team
Yes
(N=1900)
No
(N=1000)
Enrollment
registry
PCI (Xience EES)
(N=950)
CABG
(N=950)
Stratified by diabetes, SYNTAX score and
center
35. Major Inclusion Criteria Major Exclusion Criteria
Unprotected LMCAD with ≥70%
DS, or ≥50% - <70% with either i)
non-invasive evidence of LM
ischemia, ii) IVUS MLA ≤6.0
mm2, or iii) FFR ≤0.80
Syntax score ≤32
Clinical and anatomic eligibility for
both PCI and CABG as agreed to by
the local Heart Team
Prior CABG or LM PCI anytime
Prior non-LM PCI within 1 year
Need for cardiac surgery other
than CABG
Inability to tolerate DAPT for 1
year
CK-MB >ULN
36. Protocol Procedures
PCI recommendations
• Complete revasc of all ischemic territories with EES
• Provisional LM bifurcation treatment preferred
• IVUS guidance strongly recommended
• DAPT pre-loading and treatment for ≥1 year
• Routine angiographic follow-up not permitted
CABG recommendations
• Performed w/ or w/o CPB per operator discretion
• Complete anatomic revascularization of all vessels
≥1.5 mm in diameter with ≥50% DS
• Arterial grafts strongly recommended
• Epi-aortic ultrasound and TEE recommended
• Clopidogrel use during FU allowed but not mandatory
Guideline-directed medical therapy for both groups
37. Results
At 5 years, a primary outcome event had occurred in 22.0% of the
patients in the PCI group and in 19.2% of the patients in the CABG group
(difference, 2.8 percentage points; 95% confidence interval [CI], −0.9 to 6.5; P
= 0.13).
Death from any cause occurred more frequently in the PCI group than in the
CABG group (in 13.0% vs. 9.9%; difference, 3.1 percentage points; 95% CI, 0.2
to 6.1).
In the PCI and CABG groups, the incidences of definite cardiovascular
death (5.0% and 4.5%, respectively; difference, 0.5 percentage points; 95% CI,
−1.4 to 2.5) and myocardial infarction (10.6% and 9.1%; difference, 1.4
percentage points; 95% CI, −1.3 to 4.2) were not significantly different.
38. All cerebrovascular events were less frequent after PCI than
after CABG (3.3% vs. 5.2%; difference, −1.9 percentage points;
95% CI, −3.8 to 0), although the incidence of stroke was not
significantly different between the two groups (2.9% and 3.7%;
difference, −0.8 percentage points; 95% CI, −2.4 to 0.9).
Ischemia-driven revascularization was more frequent after
PCI than after CABG (16.9% vs. 10.0%; difference, 6.9 percentage
points; 95% CI, 3.7 to 10.0).
39. • PCI with 2nd generation DES (Xience) was noninferior
to CABG for clinical outcomes at 3 years following
revascularization of unprotected left main lesions
• Adverse clinical events were not uniformly distributed
from a temporal standpoint; hazard was highest with
CABG vs. PCI in the first 30 days. Between 30 days-
3 years, outcomes were inferior with PCI vs. CABG
CABG
(n = 957)
EES PCI
(n = 948)
EXCEL Results at 3Yrs
• Primary endpoint: Death/MI/stroke: PCI vs. CABG:
15.4% vs. 14.7%, pnon-inferiority = 0.018; psuperiority = 0.98
• Death/stroke/MI at 30 days: 4.9% vs. 7.9%, p = 0.008;
Between 30 days-3 years: 11.5% vs. 7.9%, p = 0.02
• 3-year stent thrombosis/graft occlusion: 0.7% vs. 5.4%,
p < 0.001; revascularization: 12.6% vs. 7.5%, p <
0.0001
Results
Conclusions
Stone GW, et al. N Engl J Med 2016;375:2223-5
Primary endpoint
pnoninferiority = 0.018
psuperiority = 0.98
%
42. Conclusion
In the EXCEL trial, treatment of patients with LMCAD and
visually-assessed low or intermediate SYNTAX scores with CoCr-
EES resulted in similar rates of the clinically meaningful
composite outcome of death, stroke or MI at 5 years.
The early benefits of PCI due to reduced peri-procedural risk were
attenuated by the greater number of events occurring during
follow-up, such that at 5 years the cumulative mean time free
from adverse events was similar with both treatments
43. • The 3-year primary outcomes are confirmed at 5-years.
• PCI showed to have better outcomes in the initial period
• After 36 months, there is an inversion of the curves showing
better outcomes in the CABG group.
• CABG was associated with a reduced risk of ID-TVR
when compared to PCI.
44. A P R O SP E C T I VE , R A N D O M I ZE D , O P E N - L A B E L ,
N O N - I N F E R I O R I T Y T R I A L , C A R R I E D O U T A T 3 6
H O SP I T A L S I N L A T VI A , E ST O N I A , L I T H U A N I A ,
G E R M A N Y , N O R W A Y , SW E D E N , F I N L A N D ,
U N I T E D K I N G D O M , A N D D E N M A R K
E N R O L L M E N T : D E C E M B E R 2 0 0 8 T O J A N U A R Y
2 0 15
NOBLE Trial
45. Inclusion Criteria
Stable angina, unstable angina, or acute
coronary syndrome
A significant left main lesion
Visually assessed
stenosis diameter >50%
or fractional flow reserve
≤0.80
Located in the ostium,
mid-shaft, or bifurcation
No more than three additional non-
complex lesions
Local interventional cardiologists and
cardiac surgeons determined that
equivalent revascularization could be
achieved with CABG or PCI
Exclusion Criteria
Additional non left main complex lesions
• Chronic total
occlusions
• Bifurcation lesions
requiring two stent
techniques
• Calcified or tortuous
vessel morphology
ST-elevation infarction within 24 h
Being considered too high-risk for CABG
or PCI
Expected survival of less than 1 year
46. Primary Endpoint
A composite of major adverse cardiac and cerebrovascular events
(MACCE)
Death from any cause
Non-procedural myocardial infarction
Repeat revascularization
Stroke
47. The NOBLE trial included 1,201 patients randomly assigned to PCI with
biolimus- eluting or sirolimus- eluting stents or to CABG surgery.
In Kaplan–Meier analyses at 5 years, MACCE rates were significantly
increased with PCI compared with CABG surgery (29% versus 19%; P =
0.0066), and the noninferiority hypothesis was not met.
Mortality was similar in both groups, but CABG surgery was
associated with significant reductions in nonprocedural myocardial
infarction, stroke, and repeat revascularization.
Procedural myocardial infarction was not assessed in this trial, and
the stent thrombosis rate was substantially higher than in the EXCEL trial,
probably reflecting the different stent types used in each trial.
In addition, an inexplicably high rate of late stroke in the PCI group
contributed to the increased risk of MACCE associated with this procedure in
the NOBLE trial
57. Conclusions
PCI did not meet non-inferiority for the primary endpoint of
5-year MACCE compared to CABG
CABG was superior to PCI
PCI resulted in higher rates of non-procedural myocardial
infarctions
Repeat revascularization was higher after PCI, primarily due
to de novo lesions and non LMCA target lesion
revascularization
All-cause mortality was similar for PCI and CABG
60. IRIS-MAIN REGISTRY
A nonrandomized, multinational, multicenter
observational study
Patients were recruited from 50 academic and
community hospitals in Asia (China, India, Indonesia, Japan,
Malaysia, South Korea, Taiwan, and Thailand)
61. OBJECTIVE METHODS
To evaluate patient
characteristics and long-
term outcomes for the
treatment of LMCA disease
over time in “real-world”
clinical practice
Authors analysed data
from a large “all-comers”
registry that includes
patients who received
medical therapy, PCI, or
CABG for unprotected
LMCA disease.
62. STUDY POPULATION
Study population was a part of IRIS-MAIN registry
5,833 with significant LMCA disease were identified
between January 1995 and December 2013 at 50
participating sites
616, 2,866 & 2,351 were treated with Medical therapy
alone, PCI & CABG respectively
Patients who had prior CABG and those who
underwent concomitant valvular or aortic surgery were
excluded
63. For the analyses, 3 historical time periods were chosen on the
basis of the generation of stent used in PCI: wave 1 (BMS) for
1995 to 2002; wave 2 (first generation DES) for 2003 to 2006;
and wave 3 (second-generation DES) for 2007 to 2013.
64. Results: Trends of patient characteristics and treatments
Over time, the proportion of patients treated with PCI rather than
CABG increased substantially, whereas the proportion of patients
who received medical therapy remained steady
During the study period, there was an increase of age for all 3
treatments, and more patients tended to present with stable
angina.
Among the patients who underwent coronary revascularization,
there was an increased risk of patient comorbidities and anatomic
complexity over time.
65. Improved chronic pharmacotherapy was found for all treatment
groups, particularly in terms of greater use of antiplatelet agents
and statins.
In the PCI group, the type of stents used dramatically changed,
and the number and length of stents significantly increased with
increasing disease complexities.
Despite an increased proportion of patients with distal bifurcation
involvement, more patients were treated with the simple 1-stent
crossover technique.
66. In the CABG group, over time, off-pump surgery was more
frequently performed, and the total number of grafts has
decreased.
Grafting using the internal mammary artery was more frequently
performed, but adoption rates varied for the radial artery.
67. Follow Up
Median follow-up time was 9.7 years, 5.6 years,
and 3.0 years for patients treated in waves 1, 2,
and 3, respectively
70. OUTCOMES
Clinical outcomes of interest were
All-cause death
Serious composite outcome (death, MI, or stroke)
Repeat revascularization
Major adverse cardiac and cerebrovascular events
(MACCE)[defined as the composite of death, MI, stroke, and repeat
revascularization]
71. Trends in Medications and Procedural and Surgical
Characteristics Over Time in Each Treatment Stratum
72. Results
Medical therapy group:
Adjusted risks for mortality; composite of death, MI, or stroke; and MACCE
gradually decreased over time
PCI group:
Trends toward decreasing risks for mortality, composite outcomes, and
repeat revascularization were also statistically significant.
CABG group:
Risks for any clinical outcomes remained relatively stable, with exception of
decreasing risk of repeat revascularization
73. Risk-Adjusted Trends of Hazard Ratios for Clinical
Outcomes Over Time in Each Treatment Stratum
74. Risk-Adjusted Trends of Hazard Ratios for Clinical
Outcomes Over Time in Each Treatment Stratum
75. Results
During all time periods Medically treated patients had an
extremely higher rate of mortality and composite of death, MI,
or stroke than those who received PCI or CABG.
Risks of mortality and composite of death, MI, or stroke were
comparable between PCI and CABG
Risks of repeat revascularization and MACCE were higher in
PCI than CABG group
Adjusted hazard ratios for risks of all clinical outcomes after PCI
relative to CABG gradually decreased over time
This suggest that gap in treatment effect between PCI and
CABG has been narrowed.
76. Risk-Adjusted HRs of Relative Clinical Outcomes
Between Treatment Strategies Over Time
77. Risk-Adjusted HRs of Relative Clinical Outcomes
Between Treatment Strategies Over Time
78. Secular Changes of Treatment Effect and Guideline Recommendations in Relation to
Medical Advances of Each Treatment Stratum for Left Main Coronary Artery Disease
79. CONCLUSIONS
Patient risk profiles and treatment of medical and
revascularization therapy have evolved remarkably over time
among patients with unprotected LMCA disease
Gap in treatment effect between PCI and CABG has
progressively diminished, mainly due to more improved
outcomes with PCI.
80. Revascularization for Unprotected Left MAIN
Coronary Artery Stenosis: COMparison of
Percutaneous Coronary Angioplasty versus
Surgical REvascularization from Multi-Center
Registry
( K O R E A N R E G I ST R Y )
The MAIN-COMPARE Study
81. Study Population
Consecutive patients with
unprotected left main coronary
disease who received stenting and
underwent CABG between
January 2000 and June 2006.
From the second quarter of 2003
(May 2003), DES have been
exclusively used as treatment
device for PCI at participating
centers.
82. January, 2000
Second quarter,
2003
June, 2006
Wave I
BMS CABG
Wave II
DES CABG
MAIN-COMPARE Registry
Stenting (BMS vs. DES) vs. CABG
Unprotected
LMCA disease
Unprotected
LMCA disease
Study Design
83. Inclusion Criteria Exclusion Criteria
Patients with unprotected left main
disease (defined as stenosis of
more than 50%) who underwent
stenting or isolated CABG.
Primary End Point
Death
Composite of death, Q-wave
myocardial infarction, or stroke
Target-vessel revascularization
• Prior CABG
• Concomitant valvular or aortic
surgery
• ST-elevation MI
• Cardiogenic shock at presentation
84. January, 2000
Second quarter
(May), 2003
June, 2006
Wave I
LMCA disease
BMS (N=318) CABG (N=448)
Wave II
LMCA disease
DES (N=784) CABG (N=690)
MAIN-COMPARE Study
Stenting (BMS or DES) vs. CABG
PCI (N=1102) CABG(N=1138)Total (N=2240)
85. Asan Medical Center
PCI patients (N=1102)
Reason for PCI
4Without suitable bypass conduits
12Concurrent severe medical illness
2Current malignancy
3Limited life expectancy
8Age ≥ 80 years and poor performance status
1073 (97%)
Physician’s preference
-”good candidate for stenting or CABG”
Patient’s preference/ Patient refused surgery
-“poor candidate for stenting”
29 (3%)Physician refused surgery
-“poor candidates for CABG”
86. Asan Medical Center
Angiographic Characteristics
Variable
Stents
(n=1102)
CABG
(n=1138) P Value
Involved location 0.04
Ostium and/or mid-shaft 50.6 46.2
Distal bifurcation 49.4 53.8
Extent of diseased vessel <0.001
Left main only 25.2 6.2
Left main plus single-vessel disease 24.0 10.5
Left main plus double-vessel disease 26.0 26.3
Left main plus triple-vessel disease 24.8 57.0
Right coronary artery disease 35.9 70.7 <0.001
Restenotic lesion 2.9 1.2 0.005
90. Asan Medical Center
Hazard Ratios for Clinical Outcomes
(Overall PCI and CABG matched cohort: 542 pairs)
Overall Patients
(N=542 pairs)
Outcome
Hazard Ratio*
(95% CI) P value
Death 1.18 (0.77-1.80) 0.45
Composite outcome
(death, Q-wave myocardial infarction, or
stroke)
1.10 (0.75-1.62) 0.61
Target-vessel revascularization 4.76 (2.80-8.11) <0.001
*HR are for the stenting group, as compared with CABG group
91. (BMS and contemporary CABG matched cohort: 207pairs)
Death: BMS and contemporary CABG matched cohort: 207pairs
92. Death, Q-MI, or Stroke
BMS and contemporary CABG matched cohort: 207pairs
94. Asan Medical Center
Hazard Ratios for Clinical Outcomes
Wave 1
(N=207 pairs)
Outcome
Hazard Ratio*
(95% CI) P value
Death 1.04 (0.59-1.83) 0.90
Composite outcome
(death, Q-wave myocardial infarction, or
stroke)
0.86 (0.50-1.49) 0.59
Target-vessel revascularization 10.70 (3.80-29.90) <0.001
*HR are for the stenting group, as compared with CABG group
(BMS and contemporary CABG matched cohort: 207pairs)
95. DEATH: DES and contemporary CABG matched cohort: 396 pairs
96. Death, Q-MI, or Stroke
DES and contemporary CABG matched cohort: 396 pairs
98. Asan Medical Center
Hazard Ratios for Clinical Outcomes
Wave 2
(N=396 pairs)
Outcome
Hazard Ratio*
(95% CI) P value
Death 1.36 (0.80-2.30) 0.26
Composite outcome
(death, Q-wave myocardial infarction, or
stroke)
1.40 (0.88-2.22) 0.15
Target-vessel revascularization 5.96 (2.51-14.10) <0.001
*HR are for the stenting group, as compared with CABG group
(DES and contemporary CABG matched cohort: 396 pairs)
99. Conclusion
In a cohort of patients with unprotected left main coronary artery disease, we
found no statistical significant difference in the risk of death and serious
composite outcomes (death, Q-wave myocardial infarction, or stroke) between
patients receiving stenting and those undergoing CABG.
These results were consistent when comparing bare-metal stents or drug-
eluting stents with concurrent CABG controls, although a statistically
nonsignificant trend was noted toward higher risk in the analysis for drug-
eluting stents.
However, the rate of target-vessel revascularization was significantly lower in
the CABG group than in the PCI group, regardless of stent type.
100. Changes in PCI Guideline Recommendations for
LMCA Disease
101. Changes in PCI Guideline Recommendations for
LMCA Disease
102. Changes in PCI Guideline Recommendations
for LMCA Disease
103. Recommendation for the type of revascularization in
patients with Left main CAD
Neumann FJ et al., European Heart Journal (2019) 40, 87–165