Lili Dong

Simple versus complex stenting strategy for coronary artery bifurcation lesions in the drug-eluting stent era: a meta-analysis of randomised trials

Background: Coronary bifurcation lesions remain a challenge for interventional cardiologists and the optimal stenting strategy has not been established in the current drug-eluting stent (DES) era. This study compared two strategies for DES treatment of coronary bifurcation lesions: a simple stenting approach (stenting only the main vessel (MV) and provisional stenting of the side branch (SB) only when bailout of the SB is necessary) versus a complex stenting approach (routinely stenting not only MV but also SB). Methods: Data sources included PubMed and conference proceedings. Prespecified criteria were met by five randomised studies comparing simple stenting strategy versus complex stenting strategy in 1553 patients with coronary bifurcation lesions. Studies reported the clinical and angiographic outcomes of efficacy and safety during a minimum of 6 months. Results: The risks of follow-up myocardial infarction (MI) (relative ratio (RR) 0.54, 95% confidence interval (CI) 0.37 to 0.78, p = 0.001) and early (in-hospital or 30-day) MI (RR 0.52, 95% CI 0.35 to 0.78, p = 0.002) were markedly lower in patients treated with the simple strategy compared to the complex strategy. There were no significant differences between the two different strategies with respect to the rates of cardiac death (RR 0.68, 95% CI 0.21 to 2.25, p = 0.53), target lesion revascularisation (TLR) (RR 0.93, 95% CI 0.62 to 1.41, p = 0.74) or definite stent thrombosis (ST) (RR 0.50, 95% CI 0.19 to 1.32, p = 0.16). The restenosis risk of MV and SB did not differ between the simple strategy group and the complex strategy group (RR 1.15, 95% CI 0.66 to 2.00, p = 0.63 and RR 1.12, 95% CI 0.80 to 1.57, p = 0.50, respectively). Conclusions: Compared to the complex strategy for DES treatment of coronary bifurcation lesions, the simple strategy was associated with a lower risk of early MI and a similar rate of angiographic restenosis. Since the complex strategy could not improve the clinical or angiographic outcome, the simple strategy can be recommended as a preferred bifurcation stenting technique in the DES era.

Meta-Analysis of Five Randomized Clinical Trials Comparing Sirolimus- Versus Paclitaxel-Eluting Stents in Patients With Diabetes Mellitus

Recent data on drug-eluting stents have shown improved clinical outcomes in patients with diabetes mellitus. However, the relative efficacy and safety of sirolimus-eluting stents (SES) compared with paclitaxel-eluting stents (PES) remains controversial. Therefore, a meta-analysis of randomized trials was performed to compare SES with PES exclusively in patients with diabetes. The published research was scanned by formal searches of electronic databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials) from January 2001 to April 2009. All randomized trials involving head-to-head comparison of SES versus PES in patients with diabetes were examined for analysis. A total of 5 randomized trials were included in the present meta-analysis, involving 1,173 patients (594 in the SES group, 579 in the PES group). SES were significantly more effective in the reduction of target lesion revascularization (5.1% vs 11.4%, odds ratio [OR] 0.41, 95% confidence interval [CI] 0.26 to 0.64, p <0.001) and angiographic binary (> or =50%) restenosis (5.6% vs 16.4%, OR 0.30, 95% CI 0.19 to 0.48, p <0.001) compared to PES. In contrast, the differences between SES and PES were not statistically significant with respect to cardiac death (2.2% vs 2.9%, OR 0.71, 95% CI 0.34 to 1.47, p = 0.35), myocardial infarction (1.5% vs 2.6%, OR 0.58, 95% CI 0.26 to 1.31, p = 0.19), and stent thrombosis (0.6% vs 1.2%, OR 0.57, 95% CI 0.18 to 0.84, p = 0.35). In conclusion, SES are superior to PES in reducing the incidences of restenosis and target lesion revascularization in patients with diabetes, with nonsignificant differences in terms of cardiac death, myocardial infarction, and stent thrombosis.

Effect of statins pretreatment on periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention: a meta-analysis

Abstract Background. Periprocedural myocardial injury remains the most common complication associated with percutaneous coronary intervention (PCI). Previous studies have demonstrated that even a small elevation of cardiac enzymes is associated with higher risk of mortality during follow-up. Objective. We performed a meta-analysis based on all currently available randomized controlled trials (RCT) to evaluate the beneficial effects of hydroxymethylglutaryl-CoA reductase inhibitors (statins) given before PCI on preventing periprocedural myocardial infarction (MI). Methods. The published literature was scanned by formal searches of electronic databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials) and conference proceedings up through August 2009. RCTs were eligible for inclusion if they compared preprocedural statins versus placebo treatment in patients not taking statins previously but scheduled for PCI and had the data of periprocedural MI reported by the trial investigators. Results. Prespecified criteria were met by 6 RCTs involving 2,088 patients. During the periprocedural period, 81 of 1,051 patients (7.7%) in the statins pretreatment group developed periprocedural MI, significantly less than 147 of 1,037 (14.2%) patients assigned to the control group (OR 0.51, 95% CI 0.38–0.67; P< 0.001). During 1-month follow-up, only 4 deaths, 7 non-periprocedural Q-wave MIs, and 4 revascularizations occurred in all 2,088 enrolled patients. The composite of death, MI, or target vessel revascularization at 1 month, essentially driven by periprocedural MI, was reported in 8.0% in the statins pretreatment group and 15.3% in the control group (OR 0.48, 95% CI 0.36–0.64; P< 0.001). Conclusions. This meta-analysis supports the effectiveness of statins pretreatment on reducing the rate of periprocedural MI in patients undergoing PCI.

REstoration of COronary flow in patients with no-reflow after primary coronary interVEntion of acute myocaRdial infarction (RECOVER)

BACKGROUND No randomized trial has been conducted to compare different vasodilators for treating no-reflow during primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction. METHODS The prospective, randomized, 2-center trial was designed to compare the effect of 3 different vasodilators on coronary no-reflow. A total of 102 patients with no-reflow in primary PCI were randomized to receive intracoronary infusion of diltiazem, verapamil, or nitroglycerin (n = 34 in each group) through selective microcatheter. The primary end point was coronary flow improvement in corrected thrombolysis in myocardial infarction frame count (CTFC) after administration of the drug. RESULTS Compared with that of the nitroglycerin group, there was a significant improvement of CTFC after drug infusion in the diltiazem and verapamil groups (42.4 frames vs 28.1 and 28.4 frames, P < .001). The improvement in CTFC was similar between the diltiazem and verapamil groups (P = .9). Compared with the nitroglycerin group, the diltiazem and verapamil groups had more complete ST-segment resolution at 3 hours after PCI, lower peak troponin T level, and lower N-terminal pro-B-type natriuretic peptide levels at 1 and 30 days after PCI. After drug infusion, the drop of heart rate and systolic blood pressure in the verapamil group was greater than that in the diltiazem and nitroglycerin groups. CONCLUSION Intracoronary infusion of diltiazem or verapamil can reverse no-reflow more effectively than nitroglycerin during primary PCI for acute myocardial infarction. The efficacy of diltiazem and verapamil is similar, and diltiazem seems safer.

Right Ventricular Regional Systolic Function and Dyssynchrony in Patients with Pulmonary Hypertension Evaluated by Three-Dimensional Echocardiography

BACKGROUND The aim of this study was to evaluate right ventricular (RV) regional systolic function and dyssynchrony in patients with pulmonary hypertension (PH) using real-time three-dimensional echocardiography. METHODS Real-time three-dimensional echocardiographic images were acquired to obtain RV regional (inflow, body, and outflow) ejection fraction (EF) and time to minimum systolic volume in 70 patients with PH and 26 normal controls. Pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance measured by echocardiography in all subjects and by right heart catheterization in 17 patients were recorded. RESULTS Inflow EF and global EF were significantly lower in patients with PH than in controls (P < .05). Body EF was significantly decreased in patients with moderate (PASP, 50-69 mm Hg) and severe (PASP ≥ 70 mm Hg) PH (P < .05). Outflow EF was significantly lowered in patients with severe PH (P < .001). The standard deviation of regional time to minimum systolic volume corrected by heart rate was significantly prolonged in patients with severe PH (P < .05). Inflow EF and global EF were negatively correlated with PASP (r = -0.731 and r = -0.769, respectively, P < .001) and with pulmonary vascular resistance (r = -0.789 and r = -0.801, P < .001). CONCLUSIONS In patients with PH, RV inflow and global systolic function was impaired in inverse relationship with PASP and pulmonary vascular resistance. RV systolic synchronicity was impaired in patients with severe PH. Evaluation of RV regional systolic function using real-time three-dimensional echocardiography may play a potential role in the noninvasive assessment of the severity of PH.

Usefulness of statins pretreatment for the prevention of postoperative atrial fibrillation in patients undergoing cardiac surgery

Abstract Background. Postoperative atrial fibrillation (AF) remains the most common arrhythmic complication following cardiac surgery. We performed a meta-analysis based on all currently available randomized controlled trials (RCTs) to confirm the hypothesis that statins pretreatment may lower the risk of postoperative AF in patients undergoing cardiac surgery. Methods and results. The published literature was scanned by formal searches of electronic databases up through August 2010. RCTs were eligible for inclusion if they compared preoperative statins treatment versus control in patients scheduled for cardiac surgery and had the data of postoperative AF reported. Pre-specified criteria were met by eight RCTs involving 841 patients. During the follow-up period, 80 of 422 patients (19.0%) in the statins pretreatment group developed postoperative AF, significantly less than 149 of 419 (35.6%) patients assigned to the control group (P < 0.001). Postoperative hospital stay was significantly shortened in patients pretreated with statins compared with the control (P < 0.01). Conclusions. This meta-analysis supports the effectiveness of statins pretreatment on reducing the incidence of postoperative AF in patients undergoing cardiac surgery.

Type A aortic dissection in patients with bicuspid or tricuspid aortic valves: a retrospective comparative study in 288 Chinese patients

OBJECTIVES The propensity for aortic aneurysm and dissection bestows bicuspid aortic valves (BAVs), the most common congenital cardiac abnormality, a potentially lethal aspect and considerable clinical concern. In the present study, we attempted to better characterize BAV patients with acute type A aortic dissection (AAD). METHODS Data from 288 consecutive patients undergoing surgery for acute AAD between December 2007 and April 2012 at our institute were retrospectively collected. Patients were categorized into BAV (n = 30) and tricuspid aortic valve (n = 258) groups to investigate their clinical and prognostic features. RESULTS BAV patients tended to have younger age, lower systolic blood pressure, higher rate of moderate-to-severe aortic stenosis and wider ascending aorta (all P < 0.05). The 30-day postoperative mortality was significantly higher among BAV patients (23.3 vs 8.1%, P = 0.016), with an elevated proportion of both cardiogenic deaths and complications. BAV patients who died during the follow-up period demonstrated higher incidence of aortic stenosis (57.1 vs 13.0%, P = 0.033), coronary artery ostium involvement (57.1 vs 4.3%, P = 0.006) and longer cardiopulmonary bypass time (190.7 ± 67.5 vs 140.3 ± 37.1 min, P = 0.035). CONCLUSIONS BAV-associated dissection, as a unique subgroup of AAD, demonstrated strikingly high postoperative mortality in a Chinese population. Moderate-to-severe aortic stenosis and dissection involving coronary artery ostium might be associated with the adverse clinical outcomes among BAV patients.

Coronary aneurysm formation following biodegradable polymer drug-eluting stent implantation

Coronary aneurysm formation is a rare complication occurring after drug-eluting stent (DES) implantation, but always predisposes to the development of late stent thrombosis. Such abnormal dilatation of stented coronary artery has been documented not only with the first-generation sirolimus-/paclitaxel-eluting stents but also with the second-generation everolimus-eluting stent [1–4]. Although exact causes of aneurysm formation remain unknown, available pathological evidence supports the hypothesis that persistent hypersensitivity reaction to the permanent polymer coated on these DESs is the most likely mechanism [5]. Recently, several novel DESs with biodegradable polymers, which carry and control the drug release during a proper period of time and after that erode and vanish from the vascular surface, have been developed and used to improve DES safety and efficacy [6,7]. We report a case of multiple coronary aneurysm formation at 10-month angiographic follow-up after implantation of a biodegradable polymer sirolimus-eluting stent. To the best of our knowledge, this is the first report of coronary aneurysm formation associated with the biodegradable polymer DES. A 65-year-old male patient with a history of hypertension was admitted to our institute because of progressive exertional chest

Atorvastatin prevents dehydromonocrotaline-induced pulmonary hypertension in beagles.

ABSTRACT Background: Pulmonary arterial hypertension is a life-threatening disease characterized by marked and sustained elevation of blood pressure in the lungs. Statins, 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase inhibitors, have been shown to attenuate the effects of pulmonary hypertension resulting from hypoxia, Monocrotaline exposure, or Monocrotaline exposure in the setting of pneumonectomy. In particular, the effects of Simvastatin have been well studied. Whether other statins, such as Atorvastatin, are capable of preventing dehydromonocrotaline-induced pulmonary hypertension in beagles has not been explored. Methods: We used eighteen 3-month-old beagles of both genders, weighing 10.3 ± 3.2 kg. The experimental animals were randomized into one of 3 groups: the control group (n = 6), the dehydromonocrotaline (DHMC) + vehicle group (n = 5), and the DHMC + Atorvastatin group (n = 7). The beagles were injected with DHMC (n = 12) on day 1, and from day 5 to day 65 they received Atorvastatin (2 mg/kg, daily by gavage) or vehicle (0.9% saline, daily by gavage) treatment. We used the thermodilution method of hemodynamic measurements at baseline and at day 65 of treatment. At day 65, pulmonary tissue was sampled for morphometry and real-time quantitative PCR. Results: After 65 days, DHMC increased mean pulmonary arterial pressure (mPAP), and this increase was prevented with Atorvastatin treatment (32 ± 11 mmHg vs. 15 ± 3 mmHg, P < .05). Hematoxylin and eosin staining demonstrated less pulmonary endothelium destruction and smooth muscle cell proliferation in the Atorvastatin-treated beagles, compared with the DHMC group. The eNOS mRNA expression was increased in the DHMC group, and this increase was prevented in the Atorvastatin-treated group. In addition, IL-1β, prepro-ET-1, TNF-α, and VEGF (vascular endothelial growth factor) mRNA expression levels were increased in the lungs of the DHMC group, and these increases were reduced toward normal levels in the Atorvastatin-treated group. Conclusion: Atorvastatin prevents the effects of monocrotaline-induced pulmonary hypertension in beagles.

Early administration of small-molecule glycoprotein IIb/IIIa inhibitors before primary percutaneous coronary intervention for ST-elevation myocardial infarction: insights from randomized clinical trials

Background: Current guidelines recommend abciximab (ReoPro) as an adjunctive pharmacologic agent to primary percutaneous coronary intervention (PPCI) for patients with ST-segment elevation myocardial infarction (STEMI). However, small-molecule glycoprotein IIb/IIIa receptor inhibitors (smGPIs), such as tirofiban (aggrastat) and eptifibatide (integrilin), are more commonly used in clinical practice. Method and Result: We performed a meta-analysis to compare the safety and efficacy of early administration of smGPIs versus abciximab before PPCI. The literature was scanned by formal searches of electronic databases from January 1990 to April 2009. A total of 4 randomized trials meeting the prespecified criteria were analyzed, involving 2040 patients. Rates of initial Thrombolysis in Myocardial Infarction Study (TIMI) 3 flow before procedure as well as complete ST resolution after PPCI were not inferior in smGPIs group compared with abciximab group (odds ratio [OR] 1.12, P = .31; and OR 1.05, P = .66, respectively). There was no significant difference in the risk of 30-day (OR 0.83, P = .54) or 8-month mortality (OR 0.78, P = .43) between smGPI and abciximab group. With regard to the safety end points, neither the major nor the minor bleeding complications in smGPIs group differed significantly from those in abciximab group (OR 1.32, P = .43; and OR 0.82, P = .37, respectively). Conclusion: This meta-analysis shows that early administration of smGPIs is as effective as abciximab in the setting of PPCI for STEMI, without an increase in bleeding complications.