Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease.We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent.In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents.In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.
Revascularization of borderline fractional flow reserve (FFR) is controversial and the morphologic characteristics of borderline FFR lesions are not well known. The objective of this study was to determine the intravascular ultrasound (IVUS) characteristics in intermediate coronary lesions with borderline FFR in patients with intermediate coronary artery stenosis (40%-70% diameter stenosis).Both IVUS and FFR were performed in a total of 228 left anterior descending arteries. We divided them into 3 groups by FFR value: ischemic (n = 46, FFR < 0.75), borderline (n = 71, FFR 0.75 to ≤0.80), and non-ischemic (n = 111, FFR > 0.80). We compared the IVUS parameters, including minimum lumen area, lesion length, plaque burden, and volumetric analysis among the 3 groups.In the IVUS analysis, the minimum lumen area was smaller (2.5 ± 0.6 vs. 2.7 ± 0.7 vs. 3.4 ± 1.2 mm, P < .001); lesion length was longer (23.6 ± 8.4 vs. 23.6 ± 7.4 vs. 17.4 ± 6.8 mm, P < .001); plaque burden was larger (76.1 ± 9.6 vs. 73.9 ± 7.5 vs. 69.8 ± 9.5%, P < .001); plaque volume was larger (173.0 ± 78.3 vs. 167.7 ± 75.0 vs. 129.5 ± 79.1 mm, P < .01); and percent atheroma volume was larger (57.9 ± 7.5 vs. 57.6 ± 6.6 vs. 53.9 ± 8.0%, P < .01) in the ischemic and borderline groups compared with the non-ischemic group, respectively. However, post-hoc analyses showed there were no significant differences between the ischemic and borderline group for all IVUS parameters.There were no differences in IVUS characteristics between borderline and functionally significant FFR, but the amount of atheromatous plaque was more severe in these 2 groups than in the non-ischemic group.
The Fractional Flow Reserve and Intravascular Ultrasound-Guided Intervention Strategy for Clinical Outcomes in Patients with Intermediate Stenosis (FLAVOUR) trial demonstrated non-inferiority of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) compared with intravascular ultrasound (IVUS)-guided PCI. We sought to investigate the cost-effectiveness of FFR-guided PCI compared to IVUS-guided PCI in Korea.
Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of evidence that has led to major recommendations in clinical practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region based on updated information in the field that including both wire- and image-based physiologic assessment. This is Part 1 of the whole consensus document, which describes the general concept of coronary physiology, as well as practical information on the clinical application of physiologic indices and novel image-based physiologic assessment.
Background: Despite the prognostic importance of the status of coronary microcirculation, there has been lacking in comparative studies on the most reliable invasive measurement for assessing microvascular integrity and myocardial viability in AMI. We compared a novel Index of Microcirculatory Resistance(IMR) to intracoronary wire-based physiologic parameters for evaluating myocardial viability after primary percutaneous coronary intervention(PCI) in AMI. Methods: After successful primary stenting for 28 patients with AMI, Doppler-derived microvascular resistance index (MVRI) and phasic flow velocity patterns were evaluated. Using a pressure-temperature sensor-tipped coronary wire, thermodilution-derived CFR(CFR thermo ) and coronary wedge pressure(P cw ) were measured and the ratio of P cw and mean aortic pressure(P cw /P a ) was calculated, along with IMR, defined as the distal coronary pressure divided by the inverse of the hyperemic mean transit time. 18 F-fluorodeoxyglucose(FDG) PET was performed after primary PCI to evaluate myocardial viability by regional percentage uptake of FDG in infarct-related segments. Results: Among Doppler-derived parameters, regional FDG uptake showed nice correlation with hyperemic averaged peak velocity(r=0.561, p=0.002), hyperemic MVRI (r= −0.452, p=0.016) and baseline deceleration time of diastolic flow velocity (r=0.505, p=0.006). In the group of pressure-derived parameters CFR thermo , P cw /P a and IMR revealed good correlations with regional FDG uptake (r=0.487, p=0.016; r= −0.469, p=0.012; r= −0.656, p<0.001, respectively). By the receiver operating characteristics curve analysis for prediction of myocardial viability, as defined by the 50% FDG-PET threshold value, the largest area under the curve was acquired by IMR and the best cut-off value of IMR for prediction of myocardial viability was 22U (sensitivity of 79%, specificity of 86% and accuracy of 81%). Conclusions: Wire-based coronary physiologic assessment is useful for the prediction of myocardial viability immediately after primary PCI. IMR, a novel index representing the microvascular integrity, is a reliable parameter for the invasive, on-site assessment of myocardial viability after primary PCI in AMI.
The amount of epicardial adipose tissue (EAT) has been demonstrated to correlate with the severity of coronary artery disease (CAD) and the CAD activity. The aim of this study is to assess the impact of EAT on long term clinical outcomes in patients with ST elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI).We analyzed the data and clinical outcomes of 761 patients (614 males, 57 ± 12 year-old) with STEMI who underwent successful primary PCI from 2003 to 2009. All patients were divided into two groups: thick EAT group, EAT ≥ 3.5 mm and thin EAT group, EAT < 3.5 mm. The primary end points were all-cause death, recurrent MI, target vessel revascularization (TVR) and major cardiac adverse events (MACEs), composite of all-cause death, recurrent MI and TVR, within 5 years.Median and mean EAT of 761 patients were 3.3 mm and 3.6 ± 1.7 mm, respectively. Mean follow up period was 46 ± 18 months. MACE-free survival rate in the thick EAT group was significantly lower than in the thin EAT group (log-rank P = 0.001). The event-free survival rate of all-cause death of the thick EAT group was significantly lower than that of the thin EAT group (log-rank P = 0.005). The TVR-free survival rate in the thick EAT group was significantly lower than in the thin EAT group (log-rank P = 0.007). The event-free survival rate of recurrent MI were not significantly different between the groups (log-rank P = 0.206). In the Cox's proportional hazard model, the adjusted hazard ratio of thick EAT thickness for TVR was 1.868 (95% confidence interval 1.181-2.953, P = 0.008).This study demonstrates that the EAT thickness is related with long term clinical outcome in patients with STEMI. The EAT thickness might provide additional information for future clinical outcome, especially TVR.
Background: Previous studies have reported possible predictors of drug-eluting stent thrombosis (ST), but data for Asians are relatively limited. This study was performed to elucidate clinical predictors of ST in Koreans. Methods and Results: From May 2003 to May 2007, consecutive patients presenting with ST were enrolled from 10 cardiovascular centers in Korea. They were compared with 2,192 controls (3,223 lesions) who had received percutaneous coronary intervention with at least 6 months of follow-up without ST. On multivariate analysis, acute myocardial infarction (AMI) as initial diagnosis, drug-eluting stents (DES) in-stent restenosis (ISR), low ejection fraction (EF), small stent diameter, left anterior descending artery intervention, and young age were independent predictors of total ST. When divided into early (ST within 30 days of index procedure) and delayed ST (ST after 30 days of index procedure), low EF, small stent diameter, DES ISR and AMI as initial diagnosis were universal risks for both early and delayed ST. The time from antiplatelet agent discontinuation to ST occurrence was significantly shorter in late compared with very late ST. Conclusions: Predictors of ST may be slightly different for early vs. delayed ST. However, low EF, small stent diameter, DES ISR lesion, and AMI as initial diagnosis were universal risk factors for both early and delayed ST cases. The relationship between antiplatelet agent discontinuation and ST occurrence seems stronger in late compared with very late ST. (Circ J 2011; 75: 1626-1632)
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