Abstract
Background
Bifurcation lesions at the time of emergent PCI for STEMI are relatively common. However, there are little data regarding their significance. The objective of this study is to evaluate the impact of bifurcation lesions in the setting of emergent percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).
Methods
In 391 patients who underwent primary and rescue PCI, the clinical characteristics, procedural success, and in-hospital cardiac events were compared retrospectively between the patients with and without bifurcation lesions. The PCI strategy was at the discretion of the operator.
Results
The culprit artery involved a bifurcation lesion in 54/391 (14%) patients. The baseline clinical characteristics between the groups with and without bifurcation lesions were similar. The majority of bifurcation lesions (81%) were seen in the left anterior ascending (LAD) artery. All lesions were treated with the provisional stenting approach, and only 2 (3%) patients required 2 stents. There were no difference in the procedural success and the final TIMI-3 flow, but PCI of bifurcation lesion required higher amount of contrast use. There was no in-hospital MACE in the bifurcation group. The peak cardiac enzyme, left ventricular function, and length of stay were similar in these 2 groups.
Conclusions
Bifurcation lesions are relatively common in emergent PCI for STEMI involving the LAD. It can be safely treated with a provisional stenting approach, and the immediate outcome is similar to non-bifurcation lesions.
1
Introduction
Bifurcation lesions have been historically shown to have a lower procedural success rate and a higher long-term adverse outcome compared to non-bifurcation lesions. Percutaneous coronary intervention (PCI) involving a bifurcation lesion is relatively common, but remains technically challenging. Although previous trials have addressed the technical issues surrounding the treatment of bifurcation lesions, such as one-stent versus two-stent, use of a “jail” wire, final Kissing balloon inflation, the best approach to treat bifurcation lesions remains controversial . Contemporary practice has shifted towards a one-stent technique, since recent studies have shown that the one-stent approach with provisional side branch intervention is as effective as a two-stent approach .
It is not uncommon to encounter bifurcation lesions during PCI for an ST-segment elevation myocardial infarction (STEMI). Since patients with STEMI are usually excluded from bifurcation trials, data are limited on the outcome of bifurcation lesions in this setting. During the emergent setting of PCI the lesions generally have a high thrombus burden and different interventional approaches may be required for optimal results. The prevalence of bifurcation lesions in two previous studies was 23% and 10.7%, and both studies reported similar clinical outcomes between the patients with and without bifurcation lesions . The purpose of this study was to evaluate the clinical impact of bifurcation lesions on primary or rescue PCI for patients with STEMI.
2
Methods
2.1
Study population
This was a retrospective analysis of 391 consecutive patients who underwent primary PCI or rescue PCI at our institution from March 2004 to December 2011. All patients who presented within 12 h after the onset of chest pain and underwent primary PCI or rescue PCI after failed thrombolysis were included.
2.2
Procedures
All patients received aspirin 325 mg pre-procedure, and heparin to maintain an ACT > 250 s during the procedure. All patients were given a loading dose of clopidogrel 600 mg before or after the procedure. The use of GP IIb/IIIa inhibitors was at the discretion of the treating physician.
The percutaneous coronary intervention was performed at the discretion of the operator, including the technical approach to the bifurcation lesion. A bifurcation lesion was defined as a lesion involving a side branch with a diameter greater than 2.25 mm . Coronary angiograms were analyzed off-line by experienced interventional cardiologists. Pre- and post-PCI TIMI flows of the main branch and side branch were evaluated. The approach to the bifurcation lesions was reviewed, including provisional approach versus 2-stent approach, the use of 2 wires, intervention to the side branch, and final kissing balloon inflations.
2.3
End-point
Medical records were reviewed to obtain in-hospital clinical outcomes, including major adverse cardiac events (MACE) which were defined as cardiac death, repeat myocardial infarction, or stroke. In addition to MACE, peak cardiac enzymes, left ventricular ejection fraction, and length of stay were documented. Considering that the majority of bifurcation lesions were in the left anterior descending (LAD) artery (81%), the clinical outcomes were separately assessed in the LAD-infarction group and the non-LAD infarction group.
2.4
Statistics
Continuous variables are expressed as means ± standard deviation and discrete variables are presented as percentages. Clinical characteristics and clinical outcomes between patients with and without bifurcation lesions were compared using the student t-test, Chi-Square test, or Fisher’s test. All tests were two-tailed, and a p-value of < 0.05 was considered significant.
2
Methods
2.1
Study population
This was a retrospective analysis of 391 consecutive patients who underwent primary PCI or rescue PCI at our institution from March 2004 to December 2011. All patients who presented within 12 h after the onset of chest pain and underwent primary PCI or rescue PCI after failed thrombolysis were included.
2.2
Procedures
All patients received aspirin 325 mg pre-procedure, and heparin to maintain an ACT > 250 s during the procedure. All patients were given a loading dose of clopidogrel 600 mg before or after the procedure. The use of GP IIb/IIIa inhibitors was at the discretion of the treating physician.
The percutaneous coronary intervention was performed at the discretion of the operator, including the technical approach to the bifurcation lesion. A bifurcation lesion was defined as a lesion involving a side branch with a diameter greater than 2.25 mm . Coronary angiograms were analyzed off-line by experienced interventional cardiologists. Pre- and post-PCI TIMI flows of the main branch and side branch were evaluated. The approach to the bifurcation lesions was reviewed, including provisional approach versus 2-stent approach, the use of 2 wires, intervention to the side branch, and final kissing balloon inflations.
2.3
End-point
Medical records were reviewed to obtain in-hospital clinical outcomes, including major adverse cardiac events (MACE) which were defined as cardiac death, repeat myocardial infarction, or stroke. In addition to MACE, peak cardiac enzymes, left ventricular ejection fraction, and length of stay were documented. Considering that the majority of bifurcation lesions were in the left anterior descending (LAD) artery (81%), the clinical outcomes were separately assessed in the LAD-infarction group and the non-LAD infarction group.
2.4
Statistics
Continuous variables are expressed as means ± standard deviation and discrete variables are presented as percentages. Clinical characteristics and clinical outcomes between patients with and without bifurcation lesions were compared using the student t-test, Chi-Square test, or Fisher’s test. All tests were two-tailed, and a p-value of < 0.05 was considered significant.
3
Results
Among 391 patients, the culprit artery was the LAD in 156 patients, the right coronary artery in 176 patients, the left circumflex artery in 45 patients, the diagonal branch in 6 patients, and a saphenous vein graft in 8 patients. The culprit lesion involved a bifurcation lesion in 54 (14%) patients, the majority of which were LAD lesions (81%). There were no differences in clinical characteristics between patients with and without bifurcation lesions ( Table 1 ). Procedural characteristics were similar between 2 groups including the stent size, success rate, and the achievement of TIMI 3 flow. The use of drug-eluting stent was higher in the bifurcation group (81% vs 55%, p < 0.001), and the mean amount of contrast use was higher in bifurcation group (249 ml vs 222 ml, p = 0.017) ( Table 1 ).
| Bifurcation N = 54 | No Bifurcation N = 337 | P | |
|---|---|---|---|
| Age | 59 ± 12 | 60 ± 14 | 0.620 |
| Men | 45 (83%) | 270 (80%) | 0.837 |
| Hypertension | 30 (56%) | 193 (57%) | 0.930 |
| Diabetes Mellitus | 19 (35%) | 105 (31%) | 0.665 |
| Dyslipidemia | 25 (46%) | 157 (47%) | 0.915 |
| Smoking | 19 (35%) | 119 (35%) | 0.892 |
| h/o myocardial infarction | 4 (3%) | 35 (10%) | 0.629 |
| Previous PCI | 8 (15%) | 55 (16%) | 1.000 |
| Previous CABG | 0 | 13 (4%) | 0.230 |
| Primary PCI | 53 (98%) | 323 (96%) | 0.764 |
| Culprit artery | |||
| LAD | 44 (81%) | 112 (33%) | < 0.001 a |
| Diagonal branch | 1 | 5 | |
| RCA | 4 | 172 | |
| LCx | 5 | 40 | |
| SVG | 0 | 8 | |
| 3 vessel disease | 12 (22%) | 96 (28%) | 0.428 |
| Stent thrombosis | 6 (11%) | 22 (7%) | 0.251 |
| TIMI 0 flow | 31 (57%) | 238 (70%) | 0.074 |
| Thrombus grade | |||
| 0 | 0 | 1 | |
| 1 | 5 | 18 | |
| 2 | 7 | 23 | |
| 3 | 6 | 22 | |
| 4 | 5 | 35 | |
| 5 | 31 | 238 | |
| Successful PCI | 54 (100%) | 329 (98%) | 0.606 |
| Stent | 53 (98%) | 315 (93%) | 0.226 |
| Drug-eluting stent | 44 (81%) | 187 (55%) | 0.0005 |
| Stent diameter (mm) | 3.3 ± 0.4 | 3.3 ± 0.5 | 1.000 |
| Stent length (mm) | 24.1 ± 11.2 | 22.7 ± 11.3 | 0.405 |
| Stent # | 1.4 ± 0.6 | 1.3 ± 0.6 | 0.263 |
| Thrombectomy use | 23 (43%) | 125 (37%) | 0.534 |
| GP IIb/IIIa use | 20 (37%) | 122 (36%) | 0.973 |
| IABP use | 11 (20%) | 59 (18%) | 0.750 |
| Contrast use (ml) | 249 ± 75 | 222 ± 72 | 0.017 |
| TIMI 3 flow | 44 (81%) | 269 (80%) | 0.920 |
| LVEF (%) | 37 ± 11 | 44 ± 13 | 0.0002 |
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