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Functional and morphological assessment of side branch after left main coronary artery bifurcation stenting with
Soo-Jin Kang1, Jung-Min Ahn, Won-Jang Kim
1Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
Insights
In left main coronary artery (LMCA) bifurcation lesions, intravascular ultrasound (IVUS) can predict functional compromise of the left circumflex artery (LCX) ostium after stenting. Post-stenting fractional flow reserve (FFR) is crucial for guiding sidebranch treatment.
Area of Science:
- Interventional Cardiology
- Cardiovascular Imaging
- Biomedical Engineering
Background:
- Hemodynamic and geometric changes in the left circumflex artery (LCX) ostium after main branch (MB) stenting in left main coronary artery (LMCA) bifurcation lesions remain unclear.
- Intravascular ultrasound (IVUS) is evaluated for its accuracy in predicting functional compromise of the sidebranch (LCX) ostium.
Purpose of the Study:
- To assess the predictive accuracy of IVUS for functional compromise of the LCX ostium post-LMCA bifurcation stenting.
- To determine the correlation between pre- and post-stenting IVUS parameters and fractional flow reserve (FFR) in the LCX.
Main Methods:
- A single-stent cross-over technique was employed in 43 patients with LMCA bifurcation lesions and <50% LCX ostial diameter stenosis (DS).
- Fractional flow reserve (FFR) in the LCX was measured post-MB stenting.
- Pre- and post-stenting IVUS of MB and sidebranch was performed.
Main Results:
- Angiographic DS >50% at the LCX ostium was seen in 42% of patients post-stenting, but only 7% had FFR <0.80.
- Pre-procedural minimal lumen area (MLA) <3.7 mm² and plaque burden >56% at the LCX ostium predicted post-stenting FFR <0.80 (AUC 0.80).
- Post-stenting LCX ostial DS >57% predicted FFR <0.80 (AUC 0.962), but post-stenting MLA showed no significant correlation with FFR.
Conclusions:
- Single-stent technique rarely leads to functional LCX compromise in LMCA bifurcation lesions with mild ostial disease.
- Small post-stenting MLA is a poor predictor of functional LCX stenosis.
- Post-stenting FFR is essential for guiding sidebranch treatment decisions.
Background:
In left main coronary artery (LMCA) bifurcation lesions, hemodynamic and geometrical change in left circumflex artery (LCX) ostium after main branch (MB) stenting has not been known. This study evaluated how accurately intravascular ultrasound (IVUS) predicts the functional compromise of the sidebranch.
Methods:
A single-stent cross-over technique was used to treat LMCA bifurcation lesions in 43 patients with LCX ostial diameter stenosis (DS) of <50%. The fractional flow reserve (FFR) in the LCX was measured after MB stenting, MB and sidebranch pullback IVUS was performed prestenting and poststenting.
Results:
After MB stenting, angiographic DS >50% at the LCX ostium was observed in 18 (42%) patients, while only 3 (7%) showed FFR <0.80. A pre-procedural minimal lumen area (MLA) of <3.7 mm(2) within the LCX ostium was predictive of a poststenting FFR <0.80, with a sensitivity of 100%, specificity of 71%, a positive predictive value (PPV) of 16%, and a negative predictive value (NPV) of 100% (area under curve 0.80, P < 0.001). Moreover, pre-procedural plaque burden of >56% at the LCX ostium predicted FFR <0.80, with a sensitivity of 100%, specificity of 65%, a PPV of 14%, and a NPV of 100% (area under curve 0.80, P < 0.001). A poststenting LCX ostial DS >57% predicted FFR <0.80 with a sensitivity of 100%, specificity of 88%, a PPV of 38% and a NPV of 100% (area under curve 0.962, P < 0.001). However, the poststenting MLA within the LCX ostium showed no significant correlation with FFR (r = 0.197, P = 0.391).
Conclusions:
In LMCA bifurcation lesions with mild LCX ostial disease, the use of single-stent technique rarely resulted in the functional LCX compromise. Because the functional LCX stenosis is poorly predicted by a small MLA, sidebranch treatment should be based on the poststenting FFR.
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