Nai-Liang Tian

Comparison of intravascular ultrasound versus angiography-guided drug-eluting stent implantation: a meta-analysis of one randomised trial and ten observational studies involving 19,619 patients.

AIMS The impact of intravascular ultrasound (IVUS) guided coronary drug-eluting stent (DES) implantation on clinical outcomes remains controversial. A meta-analysis of the currently available clinical trials investigating IVUS-guided DES implantation was undertaken. METHODS AND RESULTS We searched Medline, the Cochrane Library and other internet sources, without language or date restrictions, for published articles comparing clinical outcomes between IVUS-guided and angiography-guided DES implantation. Clinical studies with both adjusted and unadjusted data were included. Eleven studies were identified (one randomised controlled trial and 10 registries) and included in the meta-analysis with a weighted follow-up time of 20.7±11.5 months. Compared with angiography guidance, IVUS-guided DES implantation was associated with a reduced incidence of death (hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.48-0.73, p<0.001), major adverse cardiac events (HR: 0.87, 95% CI: 0.78-0.96, p=0.008) and stent thrombosis (HR: 0.58, 95% CI: 0.44-0.77, p<0.001). The incidence of myocardial infarction (HR: 0.82, 95% CI: 0.63-1.06, p=0.126), target lesion (HR: 0.90, 95% CI: 0.73-1.11, p=0.316) and target vessel (HR: 0.90, 95% CI: 0.77-1.05, p=0.195) revascularisation was comparable between the angiography and IVUS-guided arms. A repeat meta-analysis of propensity-matched studies only (six studies, n=5,300) yielded broadly similar results in terms of clinical outcomes. CONCLUSIONS IVUS-guided coronary DES implantation is associated with a significant reduction in death, MACE and stent thrombosis compared to angiography guidance. Appropriately powered randomised trials are necessary to confirm the findings from this meta-analysis.

Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review.

AIMS The present study sought to compare angiographic and clinical outcomes of a simple strategy versus a complex strategy in patients with coronary bifurcation lesions undergoing drug-eluting stent implantation. METHODS AND RESULTS Medline, the Cochrane Library, and other internet sources were searched for randomised trials comparing simple strategy versus complex strategy for treating patients with bifurcation lesions. Nine eligible randomised trials including 2,569 patients were identified. The meta-analysis showed that cardiac death (odds ratio [OR]: 0.99, 95% confidence interval [CI]: 0.40- 2.41, p=0.98) and stent thrombosis (OR: 0.64, 95% CI: 0.31-1.34, p=0.24) were similar in the simple and the complex strategy. Compared with the complex strategy, the simple strategy was associated with a reduced risk of either early or follow-up myocardial infarction (OR: 0.53, 95% CI: 0.36-0.79, p=0.002; OR: 0.60, 95% CI: 0.43-0.86, p=0.01, respectively). The overall risks of side branch restenosis (OR: 1.44, 95% CI: 0.73-2.87, p=0.30), target lesion (OR: 1.72, 95% CI: 0.95-3.12, p=0.07) and target vessel revascularisation (OR: 1.59, 95% CI: 0.94-2.69, p=0.09) were comparable between the two groups. In the true bifurcation, with large side branches, and DK-crush subgroups, there were higher rates of reintervention seen in the simple strategy than in the complex strategy. CONCLUSIONS A complex strategy remains an optional treatment for patients with coronary bifurcation lesions without severe safety concerns. A complex strategy may be an optimal treatment for true bifurcation lesions with large side branches.

Randomized Comparison of FFR-Guided and Angiography-Guided Provisional Stenting of True Coronary Bifurcation Lesions: The DKCRUSH-VI Trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI).

OBJECTIVES This study sought to compare the outcomes of fractional flow reserve (FFR)-guided and angiography (Angio)-guided provisional side-branch (SB) stenting for true coronary bifurcation lesions. BACKGROUND Angio-guided provisional SB stenting after stenting of the main vessel provides favorable outcomes for the majority of coronary bifurcation lesions. Whether an FFR-guided provisional stenting approach is superior has not been studied. METHODS A total of 320 patients with single Medina 1,1,1 and 0,1,1 coronary bifurcation lesions undergoing stenting with a provisional SB approach were randomly assigned 1:1 to Angio-guided and FFR-guided groups. SB stenting was performed for Thrombolysis In Myocardial Infarction flow grade<3, ostial SB stenosis>70%, or greater than type A dissection after main vessel stenting in the Angio-guided group and for SB-FFR<0.80 in the FFR-guided group. The primary endpoint was the 1-year composite rate of major adverse cardiac events (cardiac death, myocardial infarction, and clinically driven target vessel revascularization). RESULTS Comparing the Angio-guided and FFR-guided groups, treatment of the SB (balloon or stenting) was performed in 63.1% and 56.3% of lesions respectively (p=0.07); stenting of the SB was attempted in 38.1% and 25.9%, respectively (p=0.01); and, when attempted, stenting was successful in 83.6% and 73.3% of SBs, respectively (p=0.01). The 1-year composite major adverse cardiac event rate was 18.1% in both groups (hazard ratio: 0.91, 95% confidence interval: 0.48 to 1.88; p=1.00). The 1-year target vessel revascularization and stent thrombosis rates were 6.9% and 5.6% (p=0.82) and 1.3% and 0.6% (p=0.56) in the Angio-guided and FFR-guided groups, respectively. CONCLUSIONS In this multicenter, randomized trial, angiographic and FFR guidance of provisional SB stenting of true coronary bifurcation lesions provided similar 1-year clinical outcomes. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChiCTR-TRC-07000015).

Intravascular Ultrasound-guided Systematic Two-stent Techniques for Coronary Bifurcation Lesions and Reduced Late Stent Thrombosis

The effects of intravascular ultrasound (IVUS)‐guided complex approaches using drug‐eluting stents (DES) for coronary bifurcation lesions on clinical outcomes has not yet been studied in detail.

Endovascular stent-grafts treatment in acute aortic dissection (type B): Clinical outcomes during early, late, or chronic phases

Objective: This is a prospective study to evaluate the clinical outcomes of endovascular repair in patients with different phases of type B aortic dissection. Background: Endovascular repairing with stent‐grafts is an innovative technique for type B acute aortic dissection. There is no previous study regarding outcomes in different time phases. Methods: Sixty‐two patients underwent endovascular stent‐grafts. There were 23 in the early phase (<24 hr), 20 in the late phase (≥24 hr to 2 weeks), and 19 in the chronic phase (>2 weeks). Results: The early phase group had the lowest ratio of stent‐grafts to patient and the shortest stent‐graft length. The chronic phase group had the largest diameter of false lumen. The technical success rate was 100%; no patient died within hospital. Three patients died within 30 days, with the same death rate in every group. Compared with acute patients, the chronic group had a higher volume of contrast, a higher creatinine post‐procedure, and a higher incidence of contrast‐induced nephropathy. Multiple regression analysis demonstrated that creatinine and endoleak were independent factors in predicting late death (95% CI, 3.4–26%, P < 0.01). The overall cardiovascular event‐free survival was 88.9% ± 2.1% at 30 days, 87.2% ± 4.1% at 1 year, and 81.4% ± 6.3% at 2 years. CT angiography identified the complete or partial thrombosis of the false lumen to be 95.7%. Conclusions: Endovascular repairing with stent‐graft is safe, feasible, and able to treat type B aortic dissection in all phases. However, chronic renal dysfunction was an independent factor which contributed to a lower survival rate of chronic phase patients.

Berberine attenuates adverse left ventricular remodeling and cardiac dysfunction after acute myocardial infarction in rats: Role of autophagy

The present study aimed to test the hypothesis that berberine, a plant‐derived anti‐oxidant, attenuates adverse left ventricular remodelling and improves cardiac function in a rat model of myocardial infarction (MI). Furthermore, the potential mechanisms that mediated the cardioprotective actions of berberine, in particular the effect on autophagy, were also investigated. Acute MI was induced by ligating the left anterior descending coronary artery of Sprague‐Dawley rats. Cardiac function was assessed by transthoracic echocardiography. The protein activity/levels of autophagy related to signalling pathways (e.g. LC‐3B, Beclin‐1) were measured in myocardial tissue by immunohistochemical staining and western blot. Four weeks after MI, berberine significantly prevented cardiac dysfunction and adverse cardiac remodelling. MI rats treated with low dose berberine (10 mg/kg per day) showed higher left ventricular ejection fraction and fractional shortening than those treated with high‐dose berberine (50 mg/kg per day). Both doses reduced interstitial fibrosis and post‐MI adverse cardiac remodelling. The cardioprotective action of berberine was associated with increased LC‐3B II and Beclin‐1 expressions. Furthermore, cardioprotection with berberine was potentially related to p38 MAPK inhibition and phospho‐Akt activation. The present in vivo study showed that berberine is effective in promoting autophagy, and subsequently attenuating left ventricular remodelling and cardiac dysfunction after MI. The potential underlying mechanism is augmentation of autophagy through inhibition of p38 MAPK and activation of phospho‐Akt signalling pathways.

The ginsenoside Rg1 prevents transverse aortic constriction-induced left ventricular hypertrophy and cardiac dysfunction by inhibiting fibrosis and enhancing angiogenesis

Background: Ginsenoside Rg1, an important and active ingredient of Panax ginseng, has been shown to exert cardioprotective effects in vivo. The present study aimed to test the hypothesis that ginsenoside Rg1 attenuates cardiac dysfunction in a transverse aortic constriction (TAC)–induced left ventricular hypertrophy in vivo via proangiogenic and antifibrotic effects. Methods: This study investigated the effects of ginsenoside Rg1 in a rat model of TAC-induced left ventricular hypertrophy. Cardiac function was assessed by echocardiography. The antifibrotic and proangiogenic effects were assessed by histopathology and mRNA expression of procollagen I, III, and vascular endothelial growth factor (VEGF) through quantitative real-time PCR. The expression of phosphorylation of Akt, p38 mitogen-activated protein kinase (MAPK), hypoxia inducible factor-1 (HIF-1), and VEGF proteins were examined by Western blotting. Results: Ginsenoside Rg1 treatment significantly decreased TAC-induced myocardial fibrosis and left ventricular hypertrophy, and preserved cardiac function. Ginsenoside Rg1 administration enhanced angiogenesis by increasing the expression of HIF-1 and VEGF. These cardioprotective effects of ginsenoside Rg1 are partially related to the activation of phospho-Akt and inhibition of p38 MAPK. Conclusions: Ginsenoside Rg1 exhibited protective effect against TAC-induced left ventricular hypertrophy and cardiac dysfunction, which is potentially associated with phospho-Akt activation and p38 MAPK inhibition.

Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique

AIMS The present study aimed to compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions. METHODS AND RESULTS Between March 2004 and April 2007, 633 consecutive patients with ULMCA bifurcation lesions (232 in the one-stent group and 401 in the two-stent group) were prospectively enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularisation (TVR), at five-year follow-up. Patients in the the two-stent group were classified as DK crush (n=155) and other two-stent techniques (culotte, T-stenting, kissing stenting and classical crush, n=246). Forty-seven (16.8%) patients in the one-stent group crossed over to the two-stent group. The one-stent group was associated with an increased incidence of MI compared to the two-stent approach (10.5% vs. 5.5%, p=0.025). The crude rate of MACE at five years was 28.0% in the one-stent group and 28.4% in the two-stent group (p=0.927). DK crush was associated with a significantly decreased five-year MACE compared to the other two-stent approaches or the one-stent approach (DK crush: 14.8% vs. other two-stent approaches: 37.0%, one-stent approach: 28.0%, p<0.001). The main benefit of DK crush primarily appeared to be secondary to a reduction in TVR (7.7% vs. 30.5% vs. 18.1%, p<0.001). By Cox regression analyses, the non-DK crush two-stent technique, a high SYNTAX Score (≥33) or New Risk Stratification (NERS) score (>20), and incomplete revascularisation were shown to be independent predictors of MACE at five-year follow-up. CONCLUSIONS With distal left main true bifurcations, the two-stent technique (excluding DK crush) is an independent predictor of long-term MACE. DK crush is associated with more favourable long-term clinical outcomes. Confirmation of these findings is required from randomised controlled trials.

Diagnostic accuracy of quantitative angiographic and intravascular ultrasound parameters predicting the functional significance of single de novo lesions.

OBJECTIVES The current study aimed at determining the best cutoff value of angiographic and intravascular ultrasound (IVUS) parameters for defining fractional flow reserve (FFR) <0.8 in patients with single coronary artery lesion. BACKGROUND The correlation between angiographic or IVUS variables and FFR in patients with single coronary artery lesions has not been studied yet. METHODS Quantitative coronary analysis and IVUS and FFR measurements were used in 323 patients with a single lesion. The best angiographic and IVUS cutoff values and their predictive value for FFR<0.8 were compared using area under the receiver-operator characteristic curve (AUC). RESULTS FFR<0.8 was in 54.2%. Minimal lumen area (MLA), plaque burden (PB), lesion length (LL) and lesion at left anterior descending artery (LAD) were four predictors of FFR<0.8. LL had less value in predicting FFR<0.8. The cutoff values of PB and MLA for FFR<0.8 were 72.7% and 2.97 mm(2). MLA and PB had similar high diagnostic value for vessel size ≥ 3 mm (cutoff values: 3.02 mm(2) and 80.7%), proximal LAD lesion (cutoff values: 3.04 mm(2) and 76.5%) and unstable angina (2.82 mm(2) and 71.9%). Combination of MLA (2.82 mm(2)) and PB (80.6%) had increased diagnostic value for distal LAD lesion. Only PB (71%) had higher diagnostic value for diabetic patients. MLA and PB could not predict FFR<0.8 for vessel size<3mm, and non-LAD lesion. CONCLUSION Best cutoff value of MLA and PB for FFR<0.8 in patients with a single lesion is patient-, vessel size- and lesion location-oriented. PB has strengthened diagnostic accuracy for diabetic patients.

Crush stenting with paclitaxel-eluting or sirolimus-eluting stents for the treatment of coronary bifurcation lesions.

Two hundred forty-six patients with 252 bifurcation lesions were enrolled into a prospective, nonrandomized study to use paclitaxel-eluting or sirolimus-eluting stent for crush stenting in the treatment of coronary bifurcation lesions. Compared with the sirolimus-eluting stent group, the paclitaxel-eluting stent group had significantly higher mean late lumen and binary angiographic restenosis rates. Sirolimus-eluting stent versus paclitaxel-eluting stent recipients had significantly lower in-segment restenosis in the entire main vessel (15.7% vs 3.1%, P = .004), and simultaneous side branch and main vessel restenoses were solely detected in the paclitaxel-eluting stent group (11.9% vs 0%, P = .03). Target-lesion vessel revascularization and cumulative major adverse cardiac events rates were significantly higher in the paclitaxel-eluting versus the sirolimus-eluting stent group (17.99% vs 8.41%, P = .01; 19.4 vs 9.3%, P = .01; 23.6 vs 11.2%, P = .03). In this study with crush stenting, use of sirolimus-eluting stent, compared with paclitaxel-eluting stent, yielded significantly lower late lumen loss, restenosis, and revascularization rates, with comparable safety by 8-month follow-up.