Jing Kan

A Randomized Clinical Study Comparing Double Kissing Crush With Provisional Stenting for Treatment of Coronary Bifurcation Lesions: Results From the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) Trial

OBJECTIVES The present study aimed to investigate the difference in major adverse cardiac events (MACE) at 12 months in patients with coronary bifurcation lesions after double kissing double crush (DK crush) or provisional stenting (PS) techniques. BACKGROUND Provisional side branch (SB) stenting is preferable to DK crush because it has been associated with fewer complications. It is unknown which strategy would provide the best results. METHODS From April 2007 to June 2009, 370 unselected patients with coronary bifurcation lesions from 7 Asian centers were randomly assigned to either the DK or the PS group. Additional SB stenting in PS was required if final results were suboptimal. The primary end point was the occurrence of MACE at 12 months, including cardiac death, myocardial infarction, or target vessel revascularization (TVR). Secondary end point was the angiographic restenosis at 8 months. RESULTS There were 3 procedural occlusions of SB in the PS group. At 8 months, angiographic restenosis rates in the main vessel and SB were significantly different between the DK (3.8% and 4.9%) and the PS groups (9.7% and 22.2%, p = 0.036 and p < 0.001, respectively). Additional SB stenting in the PS group was required in 28.6% of lesions. TVR was 6.5% in the DK group, occurring significantly less often than in the PS group (14.6%, p = 0.017). There were nonsignificant differences in MACE and definite stent thrombosis between the DK (10.3% and 2.2%) and PS groups (17.3%, and 0.5%, p = 0.070 and p = 0.372, respectively). CONCLUSIONS DK crush was associated with a significant reduction of TLR and TVR in this unselected patient population. However, there was no significant difference in MACE between DK and the PS groups. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChicTR-TRC-00000015).

Comparison of one-year clinical outcomes between intravascular ultrasound-guided versus angiography-guided implantation of drug-eluting stents for left main lesions: A single-center analysis of a 1,016-patient cohort

Background The importance of intravascular ultrasound (IVUS)-guided stenting of the unprotected left main coronary artery (ULMCA) remains controversial and has not been fully studied in the subset of patients with ULMCA. This study evaluated the clinical outcome of IVUS-guided stenting using a drug-eluting stent for ULMCA. Methods A total of 1,016 consecutive patients with ULMCA stenosis who underwent drug-eluting stent implantation from January 2006 to December 2011 were prospectively registered. The primary endpoint of this nonrandomized registry was the rate of one-year major adverse cardiac events (MACE, including cardiac death, myocardial infarction, and target vessel revascularization). Stent thrombosis served as the safety endpoint. Propensity score matching was used to calculate the adjusted event rate. Results The unadjusted one-year MACE rate was 14.8% in the IVUS-guided group (n=337, 33.2%), significantly different from the 27.7% (P<0.001) in the angiography-guided group (n=679, 66.8%). After propensity score matching, 291 paired patients were matched between the two groups, and the difference in one-year MACE between IVUS-guided (16.2%) versus angiography-guided (24.4%) groups was still significant (P=0.014), mainly driven by decreased rates of cardiac death (1.7%) and target vessel revascularization (3.4%) in the IVUS-guided group when compared with 5.2% (P=0.023) and 10.0% (P=0.002) in the angiography-guided group, respectively. Although it did not reach significance (P=0.075), the adjusted one-year rate of stent thrombosis in the angiography-guided group was higher than in the IVUS-guided group. Conclusion Compared with angiography guidance, IVUS-guided treatment of ULMCA using a drug-eluting stent was associated with a significant reduction of one-year cardiac death and target vessel revascularization, resulting in less frequent one-year MACE after propensity score matching.

Serial intravascular ultrasound analysis comparing double kissing and classical crush stenting for coronary bifurcation lesions

Background: Compared with the classical crush, double kissing (DK) crush improved outcomes in patients with coronary bifurcation lesions. However, there is no serial intravascular ultrasound (IVUS) comparisons between these two techniques. Objectives: This study aimed to analyze the mechanisms of the two crush stenting techniques using serial IVUS imaging. Methods: A total of 54 patients with IVUS images at baseline, post‐stenting and eight‐month follow‐up were classified into classical (n = 16) and DK (n = 38) groups. All patients underwent final kissing balloon inflation (FKBI). Unsatisfactory kissing (KUS) was defined as the presence of wrist or >20% stenosis during FKBI at the side branch (SB) ostium. The vessels at bifurcation lesions were divided into the proximal main vessel (MV) stent, the crushed segment, the distal MV stent, the SB ostium and the SB stent body. Results: KUS and incomplete crushing were commonly observed in the classical group (62.5%, 81.3%), compared with DK group (18.0%, 39.5%, P < 0.001 and P = 0.004). The post‐stenting stent symmetry in the classical group was 71.85 ± 7.69% relative to 85.93 ± 6.09% in DK group (P = 0.022), resulting in significant differences in neointimal hyperplasia (NIH, 1.60 ± 0.21 mm2 vs. 0.85 ± 0.23 mm2, P = 0.005), late lumen loss (1.31 ± 0.81 mm2 vs. 0.55 ± 0.70 mm2, P = 0.013), and minimal lumen area (MLA, 3.57 ± 1.52 mm2 vs. 4.52 ± 1.40 mm2, P = 0.042) at the SB ostium between two groups. KUS was positively correlated with the incomplete crush and was the only predictor of in‐stent‐restenosis (ISR) at the SB ostium. Conclusion: DK crush was associated with improved quality of the FKBI and larger MLA. KUS predicted the occurrence of ISR.

Clinical Outcome of Double Kissing Crush Versus Provisional Stenting of Coronary Artery Bifurcation Lesions: The 5-Year Follow-Up Results From a Randomized and Multicenter DKCRUSH-II Study (Randomized Study on Double Kissing Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions).

Background— Provisional stenting is effective for anatomic simple bifurcation lesions. Double kissing crush stenting reduces the 1-year rate of target lesion revascularization. This study aimed to investigate the 5-year clinical results of the DKCRUSH-II study (Randomized Study on Double Kissing Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions). Methods and Results— A total of 370 patients with coronary bifurcation lesions who were randomly assigned to either the double kissing crush or provisional stenting group in the DKCRUSH-II study were followed for 5 years. The primary end point was the occurrence of a major adverse cardiac event at 5 years. Patients were classified by simple and complex bifurcation lesions according to the DEFINITION criteria (Definitions and Impact of Complex Bifurcation Lesions on Clinical Outcomes After Percutaneous Coronary Intervention Using Drug-Eluting Stents). At 5 years, the major adverse cardiac event rate (23.8%) in the provisional stenting group was insignificantly different to that of the double kissing group (15.7%; P=0.051). However, the difference in the target lesion revascularization rate between 2 groups was sustained through the 5-year follow-up (16.2% versus 8.6%; P=0.027). The definite and probable stent thrombosis rate was 2.7% in each group (P=1.0). Complex bifurcation was associated with a higher rate of target lesion revascularization (21.6%) at 5 years compared with 11.1% in patients with a simple bifurcation (P=0.037), with an extremely high rate in the provisional stenting group (36.8% versus 12.5%, P=0.005) mainly because of final kissing balloon inflation (19.4% versus 5.2%; P=0.036). Conclusions— The double kissing crush stenting technique for coronary bifurcation lesions is associated with a lower rate of target lesion revascularization. The optimal stenting approach based on the lesions’ complexity may improve the revascularization for patients with complex bifurcations. Clinical Trial Registration— URL: http://www.chictr.org. Unique identifier: ChiCTR-TRC-0000015.

Obstructive sleep apnea affects the clinical outcomes of patients undergoing percutaneous coronary intervention

Background There is a paucity of evidence regarding the association between obstructive sleep apnea (OSA) and patients undergoing percutaneous coronary intervention (PCI) for coronary artery disease. We sought to investigate whether OSA affects the clinical outcomes of patients undergoing PCI. Patients and methods All enrolled individuals treated with PCI were evaluated for OSA by polysomnography. The primary end point was defined as major adverse cardiac events (MACEs) at 2 years, including cardiac death, myocardial infarction (MI), and/or target vessel revascularization. Results A total of 340 consecutive patients undergoing PCI were assigned to the OSA (n=152, apnea–hypopnea index ≥15) and non-OSA (n=188, apnea–hypopnea index <15) groups. The incidence of OSA in patients with coronary artery disease undergoing PCI was 44.7%. Patients in the OSA group had more three-vessel disease (34.9%), increased number of total implanted stents (3.3±2.0), and longer total stent length (83.8±53.1 mm) when compared to the non-OSA group (23.4%, P=0.020; 2.8±1.9, P=0.007; 68.7±48.4, P=0.010). After a median follow-up of 2 years, the incidence of MACEs was significantly higher in patients with OSA (25.0% vs 16.0%, P=0.038), mainly driven by the increased periprocedural MI (19.2% vs 11.2%, P=0.038) in the OSA group. By Cox regression multivariable analysis, the independent predictor of MACEs was OSA (hazard ratio: 1.962, 95% confidence interval: 1.036–3.717, P=0.039). Conclusion There was a high prevalence of moderate-to-severe OSA in patients undergoing PCI, and OSA was associated with significantly increased MACE rate, mainly due to the increase in periprocedural MI rate.

The acute changes of fractional flow reserve in DK (double kissing), crush, and 1-stent technique for true bifurcation lesions.

BACKGROUND While many studies confirmed the importance of fractional flow reserve (FFR) in guiding complex percutaneous coronary interventions (PCI), data regarding the significance of FFR for bifurcation lesions are still lacking. METHODS Between October 2008 and October 2009, 51 patients with true bifurcation lesions were consecutively enrolled and randomized into double kissing (DK) crush (n = 25), and provisional 1-stent (n = 26) groups. FFR measurements at baseline and hyperemia were measured at pre-PCI, post-PCI, and at 8-month follow-up. RESULTS Clinical follow-ups were available in 100% of patients while only 33% of patients underwent angiographic follow-up. Baseline clinical and angiographic characteristics were matched between the 2 groups. Pre-PCI FFR of the main branch (MB) in the DK group was 0.76 +/- 0.15, which was significantly lower than in the provisional 1-stent group (0.83 +/- 0.10, P = 0.029). This difference disappeared after the PCI procedure (0.92 +/- 0.04 vs. 0.92 +/- 0.05, P = 0.58). There were no significant differences in terms of baseline, angiographic, procedural indexes, and FFR of side branch (SB) between the 2 treatment arms. However, immediately after PCI, the patient with DK crush had higher FFR in the SB as compared to the provisional 1-stent group (0.94 +/- 0.03 vs. 0.90 +/- 0.08, P = 0.028, respectively) and also they had lower diameter stenosis (8.59 +/- 6.41% vs. 15.62 +/- 11.69%, P = 0.015, respectively). CONCLUSION In the acute phase, immediately after PCI for bifurcation lesion, DK crush stenting was associated with higher FFR and lower residual diameter stenosis in the SB, as compared with the provisional 1-stent group.

Analysis of Serum MicroRNAs as Potential Biomarker in Coronary Bifurcation Lesion

Recent evidence suggests that cell-derived circulating miRNAs may serve as the biomarkers of cardiovascular diseases. However, no study has investigated the potential of circulating miRNAs as biomarker for coronary bifurcation lesion. In this study, we aimed to characterize the miRNA profiles that could distinguish coronary bifurcation lesion and identify potential miRNAs as biomarkers of coronary bifurcation lesion. We employed miRNA microarray to screen serum miRNAs profiles of patients with coronary bifurcation lesion and coronary nonbifurcation lesions. We identified 197 miRNAs differentially expressed, including 150 miRNAs upregulated and 47 miRNAs downregulated. We chose 3 miRNAs with significant differences for further testing in 200 patients. RT-PCR analysis of serum samples confirmed that miR30d was upregulated and miR1246 was downregulated in the serum of coronary bifurcation lesion patients compared with nonbifurcation lesion patients. Our findings suggest that these miRNAs may have a role in the pathogenesis of coronary bifurcation lesion and may represent novel biomarkers for the diagnosis and prognosis of coronary bifurcation lesion.

Acute Effects of Nicardipine and Esmolol on The Cardiac Cycle, Intracardiac Hemodynamic and Endothelial Shear Stress in Patients With Unstable Angina Pectoris and Moderate Coronary Stenosis: Results From Single Center, Randomized Study

OBJECTIVE This study aimed to compare the acute effects of nicardipine and esmolol on hemodynamic and endothelial shear stress (ESS) in patients with unstable angina (UA) and moderate coronary stenosis (MCS). BACKGROUND Nicardipine and esmolol exhibit cardioprotection via different mechanisms. However, their acute effects on hemodynamic and ESS are still unknown. METHODS One-hundred sixteen patients with UA and MSC were randomly divided into nicardipine (n = 59) and esmolol (n = 57) groups. Drugs were injected as a bolus followed by continuous infusion to achieve the steady states defined as the mean blood pressure (MBP) reduced by ≥ 10% or a heart-rate change by ≥ 15 bpm, lasting for at least 10 min. The aortic pressure (AP), EKG, blood velocity, right atrial pressure, distal coronary pressure (DCP), systolic time (ST), isovolumetric diastolic time (IVDT), speed filling time (SFT), and ESS were simultaneously calculated at baseline and steady states. RESULTS Both drugs significantly reduced blood pressure and rate-pressure load. Infusion of nicardipine was associated with negative remodeling of the distal segment (P= 0.005). Esmolol, rather than nicardipine, increased minimal lumen diameter (P= 0.040), prolonged SFT (0.34 ± 0.03 s vs. 0.41 ± 0.03 s, P < 0.001), reduced DCP (P < 0.001) and increased blood velocity (33.65 ± 1.07 cm/s vs. 43.36 ± 1.25 cm/s, P < 0.001) at SFT stages, with increased blood-flow (P < 0.001). Both drugs increased downstream ESS. Esmolol significantly reversed abnormally increased ESS (P < 0.001) and increased upstream ESS compared with nicardipine (P < 0.001). CONCLUSION Beyond a similar reduction of AP, patients with UA and MCS could benefit more from the reduction of heart rate induced by esmolol (ChiCTR-TRC-10000964).

Real Polymer‐Free Sirolimus‐ and Probucol‐Eluting Versus Biodegradable Polymer Sirolimus‐Eluting Stents for Obstructive Coronary Artery Disease: DKPLUS‐Wave 1, a Multicenter, Randomized, Prospective Trial

BACKGROUND Polymer-free sirolimus- and probucol-eluting stents (Real Dual drug-eluting stents [DES]) is as effective as first-generation DES in treating coronary artery stenosis. It is unknown whether sirolimus-eluting stents containing biodegradable polymer (Excel) would be superior to real Dual DES. This study aimed to investigate the difference in target vessel revascularization (TVR) at 12 months in patients with coronary artery disease treated by the implantation of Dual DES or Excel stents. METHODS Three hundred and forty-six patients with de novo coronary artery disease were recruited from six centers in China and randomly assigned to either the Dual DES or the Excel group. The primary endpoint was the occurrence of TVR at 12 months. The secondary endpoint was angiographic in-stent restenosis and late lumen loss at 13 months. Stent thrombosis (ST) served as the safety endpoint. Dual anti-platelet therapy (DAPT) was prescribed for 6 months. RESULTS Clinical follow-up for 12 months and repeat angiography at 13 months were available in 100% and >90% of patients, respectively. The ISR and in-stent late loss were significantly different between the Excel (3.1%, 0.09 ± 0.11 mm) and the Dual DES (19.5%, 0.36 ± 0.32 mm, P < 0.001, P < 0.001, respectively) groups. The TVR (3.5%) in the Excel group was significantly less than in the Dual DES group (13.9%, P = 0.001). The ST rate beyond 12 months in the Dual DES group was 0%, and this was 1.2% in the Excel group (P = 0.499). CONCLUSIONS The Excel stent was statistically superior to the Dual DES in terms of restenosis, late loss, and TVR for long lesions.

Crush stenting with drug-eluting stents: relevance of coronary bifurcation lesion location on angiographic and clinical outcomes.

Data on the relevance of the location of coronary bifurcation lesions treated by crush stenting with outcomes were limited.