Sung-Han Yoon

Meta-Analysis of Outcomes After Intravascular Ultrasound–Guided Versus Angiography-Guided Drug-Eluting Stent Implantation in 26,503 Patients Enrolled in Three Randomized Trials and 14 Observational Studies

There are conflicting data regarding the benefit of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) over angiography-guided PCI. Since the last meta-analysis was published, several new studies have been reported. We performed a comprehensive meta-analysis to evaluate the clinical impact of IVUS-guided PCI with drug-eluting stent compared with conventional angiography-guided PCI. This meta-analysis included 26,503 patients from 3 randomized and 14 observational studies; 12,499 patients underwent IVUS-guided PCI and 14,004 underwent angiography-guided PCI. Main outcome measures were total mortality, myocardial infarction (MI), stent thrombosis, and target lesion revascularization (TLR). IVUS-guided PCI was significantly associated with more stents, longer stents, and larger stents. Regarding clinical outcomes, IVUS-guided PCI was associated with a significantly lower risk of TLR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.66 to 1.00, p=0.046). In addition, the risk of death (OR 0.61, 95% CI 0.48 to 0.79, p<0.001), MI (OR 0.57, 95% CI 0.44 to 0.75, p<0.001), and stent thrombosis (OR 0.59, 95% CI 0.47 to 0.75, p<0.001) were also decreased. In conclusion, our meta-analysis demonstrated that IVUS-guided PCI was associated with lower risk of death, MI, TLR, and stent thrombosis after drug-eluting stent implantation.

Intravascular Ultrasound-Derived Minimal Lumen Area Criteria for Functionally Significant Left Main Coronary Artery Stenosis

OBJECTIVESnThis study sought to evaluate the intravascular ultrasound (IVUS) minimal lumen area (MLA) for functionally significant left main coronary artery (LMCA) stenosis using fractional flow reserve (FFR) as the standard.nnnBACKGROUNDnThe evaluation of significant LMCA stenosis remains challenging.nnnMETHODSnWe identified 112 patients with isolated ostial and shaft intermediate LMCA stenosis (angiographic diameter stenosis of 30% to 80%) who underwent IVUS and FFR measurement.nnnRESULTSnThe FFR was ≤0.80 in 66 LMCA lesions (59%); these exhibited smaller reference vessels, smaller minimal lumen diameter, greater diameter of stenosis, longer lesion length, smaller MLA, larger plaque burden, and more frequent plaque rupture. The independent factors of an FFR of ≤0.80 were plaque rupture (odds ratio [OR]: 4.47; 95% Confidence Interval (CI): 1.35 to 14.8; p = 0.014); body mass index (OR: 1.19; 95% CI: 1.00 to 1.41; p = 0.05), age (OR: 0.95; 95% CI: 0.90 to 1.00; p = 0.031), and IVUS MLA (OR: 0.37; 95% CI: 0.25 to 0.56; p < 0.001). The optimal IVUS MLA cutoff value for an FFR of ≤0.80 was 4.5 mm(2) (77% sensitivity, 82% specificity, 84% positive predictive value, 75% negative predictive value, area under the curve: 0.83, 95% CI: 0.76 to 0.96; p < 0.001) overall and 4.1 to 4.5 mm(2) in various subgroups. Adjustment for the body surface area, body mass index, and left ventricular mass did not improve the diagnostic accuracy of the IVUS MLA.nnnCONCLUSIONSnIn patients with isolated ostial and shaft intermediate LMCA stenosis, an IVUS-derived MLA of ≤4.5 mm(2) is a useful index of an FFR of ≤0.80.

Left Main Coronary Artery Disease

Left main coronary artery (LMCA) disease is the highest-risk lesion subset of ischemic heart disease, and has traditionally been an indication for coronary artery bypass grafting (CABG). Recent evidence suggests comparable clinical outcomes between percutaneous coronary intervention (PCI) and CABG for LMCA disease, with similar rates of mortality and serious composite outcomes, a higher rate of stroke with CABG, and a higher rate of repeat revascularization with PCI. These results have been translated to the current guideline recommendation that PCI is a reasonable alternative to CABG in patients with low to intermediate anatomic complexity. However, how the characteristics, treatment, and clinical outcomes of patients with unprotected LMCA disease have evolved over time has not yet been fully evaluated. We therefore described secular trends in the characteristics and long-term outcomes of unprotected LMCA disease using real-world clinical experience from the IRIS-MAIN (Interventional Research Incorporation Society-Left MAIN Revascularization) registry together with a broad review of this topic.

Successful Recanalization of Native Coronary Chronic Total Occlusion Is Not Associated With Improved Long-Term Survival

OBJECTIVESnThe purpose of this study was to evaluate long-term clinical outcomes after drug-eluting stent-supported percutaneous coronary intervention (PCI) for native coronary total occlusion (CTO).nnnBACKGROUNDnThe benefit of successful recanalization of CTO on prognosis remains uncertain.nnnMETHODSnBetween March 2003 and May 2014, 1,173 consecutive patients with CTO of native coronary vessels requiring PCI were enrolled. Drug-eluting stent implantation was performed in all successful procedures (1,004 patients, 85.6%).nnnRESULTSnDuring a median follow-up of 4.6 years, the adjusted risks of all-cause mortality (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.53 to 2.04; p = 0.92) and the composite of death or myocardial infarction (HR: 1.05; 95% CI: 0.56 to 1.94; p = 0.89) were found to be comparable between patients with successful and failed CTO-PCI, whereas the adjusted risk of target vessel revascularization (HR: 0.15; 95% CI: 0.10 to 0.25; p < 0.001) and coronary artery bypass grafting (HR: 0.02; 95% CI: 0.006 to 0.06, p < 0.001) was significantly higher in patients with failed CTO-PCI. Among patients (n = 879) in whom complete revascularization for non-CTO vessels was performed, the risk of death or the composite of death or myocardial infarction were not found to differ between patients who underwent successful recanalization of the remaining CTO and patients who did not. This finding was consistent regardless of whether the patient had a multivessel disease including CTO or only had a single CTO disease.nnnCONCLUSIONSnSuccessful CTO-PCI compared with failed PCI was not associated with a lesser risk for mortality. However, successful CTO-PCI was associated with significantly less subsequent coronary artery bypass grafting.

Effect of Statin Treatment on Modifying Plaque Composition: A Double-Blind, Randomized Study.

BACKGROUNDnHow statins alter the natural course of coronary atherosclerosis with compositional changes remains unclear.nnnOBJECTIVESnThis study aimed to determine the effect of statin therapy on modifying plaque composition.nnnMETHODSnThe STABLE (Statin and Atheroma Vulnerability Evaluation) prospective, single-center, double-blind, randomized study evaluated the effect of statins on functionally insignificant coronary stenoses. We randomly assigned 312 patients with a virtual histology (VH) intravascular ultrasound-defined fibroatheroma-containing index lesion to rosuvastatin 40 mg versus 10 mg (2:1 ratio). In 225 (72%) patients, grayscale- and VH-intravascular ultrasound were completed at baseline and 12 months. The primary endpoint was the change in VH-defined percent compositional volume within the target segment from baseline to follow-up in the per-protocol analysis set.nnnRESULTSnPercent necrotic core (NC) volume within the target segment significantly decreased from 21.3 ± 6.8% to 18.0 ± 7.5% during 1-year follow-up, whereas the percent fibrofatty volume increased (11.7 ± 5.8% vs. 14.8 ± 9.3%; all p < 0.001). Percent fibrous (59.4 ± 7.8% vs. 59.2 ± 8.6%) and dense calcium (7.6 ± 5.1% vs. 7.8 ± 5.6%) volumes were unchanged. Frequencies of VH (55% vs. 29%) decreased significantly. Normalized total (202.9 ± 72.3 mm(3) vs. 188.5 ± 67.8 mm(3); p = 0.001) and percent (51.4 ± 8.3% vs. 50.4 ± 8.8%; p = 0.018) atheroma volumes decreased. Independent predictors of percent NC volume change were body mass index (β = 0.37; 95% confidence interval [CI]: 0.05 to 0.70), high sensitivity C-reactive protein (β = -3.16; 95% CI: -5.64 to -0.69), and baseline percent NC volume (β = -0.44; 95% CI: -0.68 to -0.19; all p < 0.05). VH-defined percent compositional volume changes in the rosuvastatin 40- and 10-mg groups were similar.nnnCONCLUSIONSnRosuvastatin reduced NC and plaque volume and decreased thin-cap fibroatheroma rate. There were no significant differences between high- versus moderate-intensity rosuvastatin. (Statin and Atheroma Vulnerability Evaluation [STABLE]; NCT00997880).

Temporal Trends in Revascularization Strategy and Outcomes in Left Main Coronary Artery Stenosis Data From the Asan Medical Center-Left Main Revascularization Registry

Background—Changes over time in revascularization strategies and outcomes among patients with unprotected left main coronary artery stenosis remain largely unknown. Methods and Results—A total of 2618 consecutive patients with unprotected left main coronary artery stenosis who underwent revascularization were identified from the ASAN Medical Center-Left MAIN Revascularization registry and classified by time periods: bare metal stent (wave 1, 1995–1998), early drug-eluting stents (wave 2, 2003–2006), and late drug-eluting stents (wave 3, 2007–2010). Primary end point was major adverse cerebrocardiovascular events (the composite of death, myocardial infarction, repeat revascularization, and stroke). During the study period, 1124 patients underwent percutaneous coronary intervention (PCI) and 1494 patients underwent coronary artery bypass grafting. The proportion of PCI significantly increased from 35% to 52% between waves 1 and 3. In patients receiving PCI, the risk-adjusted incidence rate of major adverse cerebro-cardiovascular events decreased from 20.18 cases per 100 person-years in wave 1 to 6.77 cases per 100 person-years in wave 3 (P<0.001 for trend). Death, the composite of death, myocardial infarction, stroke, and repeat revascularization were also significantly decreased by 40%, 35%, and 46%, respectively. The risk-adjusted incidence rate of major adverse cerebrocardiovascular events did not change in patients receiving coronary artery bypass grafting. The difference major adverse cerebrocardiovascular events risk between PCI and coronary artery bypass grafting progressively reduced (adjusted hazard ratio [95% confidence interval], 0.33 [0.23–0.47]; 0.53 [0.35–0.80]; and 1.01 [0.68–1.49] from wave 1 to wave 3. Conclusions—The outcomes of unprotected left main coronary artery PCI have significantly improved over time. In addition, more patients received PCI for unprotected left main coronary artery stenosis in recent years.

Complete versus incomplete revascularization in patients with multivessel coronary artery disease treated with drug-eluting stents

BACKGROUNDnThe clinical impact of completeness of revascularization on adverse cardiovascular events remains unclear among patients with multivessel coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).nnnMETHODSnThis analysis included consecutive patients with multivessel CAD, who underwent PCI with drug-eluting stents (DES) during the period from January 1, 2003, through to December 31, 2013. We compared the outcomes in patients, who achieved complete (CR) versus incomplete revascularization (IR) at the time of PCI. The primary outcome was death from any cause. Secondary outcomes were the rates of myocardial infarction (MI), stroke, and repeat revascularization. Propensity-score matching was used to assemble a cohort of patients with similar baseline characteristics.nnnRESULTSnAmong 3901 patients with multivessel CAD treated with DES, 1402 pairs of similar propensity scores in each group of CR and IR were identified. At a median follow-up of 4.9 years (interquartile range, 2.4-7.5), IR was associated with a similar risk of death (hazard ratio [HR], 1.03; 95% CI, 0.80-1.32; P=.83) as compared with CR. IR was also associated with similar risks of stroke (HR, 1.26; 95% CI, 0.76-2.09; P=.37) and repeat revascularization (HR, 1.15; 95% CI, 0.93-1.41; P=.19), but associated with a higher risk of MI (HR, 1.86; 95% CI, 1.08-3.19; P=.024) compared to CR.nnnCONCLUSIONSnAmong patients with multivessel CAD treated with DES, as compared with CR, IR was associated with similar risk of death. However, IR was associated with a higher risk of MI during follow-up.

Trends in Outcomes of Revascularization for Left Main Coronary Disease or Three-Vessel Disease With the Routine Incorporation of Fractional Flow Reserve in Real Practice

Impact of fractional flow reserve guidance on revascularization strategies and outcomes for severe coronary artery disease was unclear. We evaluate changes in treatment strategy and clinical outcomes and to compare the effectiveness between percutaneous coronary intervention (PCI) with second-generation drug-eluting stents and coronary artery bypass graft surgery (CABG) in severe coronary artery disease patients before and after routine use of FFR. From January 2008 to December 2011, we enrolled 2,612 patients with significant left main coronary artery disease or 3-vessel disease. We obtained data of patients before (from January 2008 to December 2009) and after (January 2010 to December 2011) the routine use of FFR. We used propensity score matching to compare the rate of primary outcomes (death, myocardial infarction, stroke, or repeat revascularization [Major adverse cardiovascular and cerebral event; MACCE]) at 1xa0year. Introduction of routine FFR use reduced the proportion of patients receiving CABG from 54% to 43% (p <0.001). The risk of MACCE before routine FFR use was significantly higher in the PCI group than the CABG group (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.09 to 3.03, pxa0= 0.021), whereas that after routine FFR use was not significantly different between the groups (HR 1.22, 95% CI 0.59 to 2.52, pxa0= 0.59). The risk of MACCE in patients receiving revascularization lowered after routine FFR use compared with that before (HR 0.57, 95% CI 0.38 to 0.85, pxa0= 0.005). In conclusion, routine incorporation of FFR resulted in improved PCI outcomes, comparable with concurrent CABG in patients with severe coronary artery disease who received revascularization.

Comparison of second- and first-generation drug eluting stent for percutaneous coronary chronic total occlusion intervention.

BACKGROUNDnThe performance of contemporary second-generation drug-eluting stents (DESs) for percutaneous chronic total occlusion (CTO) intervention is not well established. The present study compared the efficacy and safety outcomes of second-generation DESs with those of first-generation DESs in CTO-percutaneous coronary intervention (PCI).nnnMETHODSnThis retrospective analysis included 1049 consecutive CTO patients who underwent successful DES implantation (first-generation; 487 vs. second-generation; 562 patients) between March 2003 and August 2014. The primary endpoint was the composite of all-cause death, Q-wave myocardial infarction (MI), or target-vessel revascularization (TVR).nnnRESULTSnDuring a follow-up of 3 years, the primary endpoint incidence was 10.1% for second- and 7.7% for first-generation DES (p=0.30). After multivariable adjustment, there was no significant difference between these groups in terms of the risk of composite of death, Q-wave MI, or TVR (Hazard ratio [HR] 1.42, 95% confidence interval [CI] 0.88-2.28, p=0.15) nor in the individual risks of death (adjusted HR 1.33, 95% CI 0.69-2.56, p=0.39), Q-wave MI (adjusted HR 1.15, 95% CI 0.30-4.47, p=0.84) and TVR (adjusted HR 1.06, 95% CI 0.52-2.15, p=0.87). The incidence of definite/probable stent thrombosis was relatively low (0.5% vs.0.9%, p=0.17) throughout the follow-up period.nnnCONCLUSIONnThe 3-year clinical outcomes of patients treated with second-generation DESs are comparable to those treated with first-generation DESs for CTO-PCI.

Plaque structural stress assessed by virtual histology-intravascular ultrasound predicts dynamic changes in phenotype and composition of untreated coronary artery lesions

BACKGROUND AND AIMSnWe aimed to determine whether finite element analysis (FEA)-derived plaque structural stress (PSS) analysis can predict serial changes in atheroma volume, type, and tissue composition within a fibroatheroma-containing target segment.nnnMETHODSnOverall, 210 patients (210 untreated coronary artery lesions) underwent serial (baseline and 12-month follow-up) grayscale- and virtual histology (VH)-intravascular ultrasound (IVUS). Baseline PSS was assessed at the minimal lumen and at the maximum necrotic core (NC) sites.nnnRESULTSnOverall, there was a significant decrease in %NC volume. The highest PSS tertile was associated with a smaller on-statin reduction in %NC volume (-1.55xa0±xa01.03% in the highest vs.xa0-5.18xa0±xa01.12% in the lowest tertile, pxa0=xa00.025). Of the 115 lesions with baseline VH-thin cap fibroatheroma (TCFA), 36 (31%) showed persistent VH-TCFA at follow-up. Five of the 95 lesions with baseline thick-cap fibroatheroma evolved into VH-TCFA. Independent predictors of VH-TCFA at follow-up (including persistent and new VH-TCFAs) were diabetes mellitus (odds ratio [OR]xa0=xa03.87, 95% CIxa0=xa01.58-9.47), a large MLA (ORxa0=xa01.39, 95% CIxa0=xa01.10-1.75), a greater percent atheroma volume (ORxa0=xa01.12, 95% CIxa0=xa01.05-1.19), VH-TCFA at baseline (ORxa0=xa08.01, 95% CIxa0=xa02.73-23.50), and a higher superficial PSS at the maximum NC site (ORxa0=xa01.02, 95% CIxa0=xa01.00-1.03), (all pxa0<xa00.05). Independent determinants of the serial change in %NC volume were high-sensitive C-reactive protein (βxa0=xa0-2.79, 95% CIxa0=xa0-5.31 toxa0-0.27), baseline %NC volume (βxa0=xa0-0.70, 95% CIxa0=xa0-0.84 toxa0-0.56), and superficial PSS at the maximum NC site (βxa0=xa00.05, 95% CIxa0=xa00.01-0.08), (all pxa0<xa00.05).nnnCONCLUSIONSnAn elevated PSS was more likely associated with an increase in atheroma volume, a smaller on-statin reduction in %NC volumes, and the presence of VH-TCFA at follow-up. Morphologic and hemodynamic assessment by utilizing VH-IVUS may help understand and predict atherosclerotic progression.