CardioSource WorldNews Interventions | Page 31

FIGURE Culotte Stenting

Major adverse cardiac events Cumulative hazard (%)

10

8

6

4

2

0

Complex PCI Non-complex PCI

3.61 % vs . 2.01 % 100-patient / year ; IRD = + 1.60 % Adjusted HR : 1.98 ; 95 % CI : 1.50 — 2.60 ; p < 0.0001

Importantly , background therapy was really optimized ion this trial , with almost universal use of angiotensin-converting enzyme inhibitors and beta-blockers . Also , patients with nonischemic cardiomyopathy have lower rates of sudden cardiac death and of death from any cause than do patients with ischemic HF . Moreover ( and unlike previous ICD trials ), 58 % of patients received cardiac resynchronization therapy ( CRT ).

There was a suggestion of a differential response according to age in the DANISH trial , with a possible benefit of ICD therapy with regard to death from any cause among younger patients (< 68 years of age ). In an accompanying commentary , John J . V . McMurray , MD , noted that ICDs are expensive and not without adverse effects , meaning they should be avoided in patients who are unlikely to obtain a worthwhile benefit . Dr . McMurray wrote : “ These considerations highlight the need to target ICDs to the patients most likely to benefit — that is , those who remain at high absolute risk for sudden cardiac death despite receiving the best available pharmacologic and device therapy . The results of the DANISH trial , coupled with the generally infrequent use of ICDs globally , should open a debate about whether it is ethical to conduct new ICD trials involving the highest-risk patients . The challenge is how to identify such patients .”

In a press conference , Mariell Jessup , MD , of the University of Pennsylvania and the Presbyterian Medical Center of Philadelphia , said “ This is the first trial looking at the use of ICDs in the setting of modern therapy so I think this was really an appropriate trial .” However , she said the big problem we have today is this : not enough ICDs are being used in patients with reasonable life expectancy . She said , “ No country is putting in enough ICDs for patients who can expect to live more than 1 year .” – New England Journal of Medicine

AMERICA ( The Study ) Fails Guidelines were recently updated upgrading multivessel primary PCI in hemodynamically stable patients with STEMI from Class III ( Harm ) to a Class IIb recommendation . The writing committee did not endorse routine PCI of non-culprit lesions but instead supported it as an option for patients based on clinical data , lesion severity / complexity , and risk of contrast nephropathy . 2

What about high-risk patients , in general ? At ESC , investigators presented – let ’ s call it a French- AMERICA study . Jean-Philippe Collet , MD , PhD , from the Institut de Cardiologie Hopital Pitié- Salpetrière ( Paris , France ), presented the results of the AMERICA ( Active detection and Management of the Extension of atherothrombosis in high Risk coronary patients In comparison with standard of Care for coronary Atherosclerosis ).

Patients were randomized to a proactive prevention program including revascularization of asymptomatic multisite artery disease when appropriate , lifestyle changes , and an aggressive pharmacological approach ( n = 263 ), or to a more conventional strategy based on treatment of CAD and only symptomatic extra-coronary lesions ( n = 258 ).

These patients were considered high risk based on either recently diagnosed 3-vessel disease ( within the past 6 months ) or ACS in the past month ( in patients ≥75 years old ). Nevertheless , detecting and treating the asymptomatic sites of stenosis did not improve 2-year outcomes compared to a more traditional approach of managing only symptomatic lesions .

Professor Collet said an aggressive secondary prevention strategy is probably best in these highrisk patients , which appears to be the standard of care already . He added , “ We do not need to systematically identify asymptomatic multi-site artery disease in these high risk patients .”

The Culotte ( Stent ) Becomes Fashionable For provisional side-branch stenting , T-and-protrusion ( TAP ) stenting and culotte stenting are both compatible with current recommendations , although a recent European consensus statement 3 gave first place to some form of T-stenting ( such as TAP stenting ).

Not sure how it won top billing given there has been no randomized study comparing TAP stenting with culotte stenting in patients requiring side-branch stenting , but to fill this gap in evidence Miroslaw Ferenc , MD , PhD , and colleagues ( University Heart Center Freiburg , Bad Krozingen , Germany ) performed the randomized ‘ Bifurcations Bad Krozingen ’ ( BBK ) II trial .

During the procedure , if a side-branch stent was needed and the lesion was deemed amenable for both stenting techniques , patients were randomized to either TAP stenting ( n = 150 ) or culotte stenting ( n = 150 ). The primary endpoint was maximal in-stent percent diameter stenosis of the bifurcation lesion based on follow-up quantitative coronary angiography at 9 months .

Compared with TAP stenting , culotte stenting was associated with a significantly lower incidence of angiographic restenosis , although there was only a trend showing an advantage for culotte stenting based on 1-year target-lesion revascularization and target-lesion failure ( TABLE 2 next page ).

This difference in the primary endpoint was driven almost entirely by differences in the side branch , where the mean percent diameter stenosis was 16 % in the culotte arm versus 22 % in the TAP arm ( p = 0.029 ). In contrast , there were no differences between techniques in the percent diameter stenosis in the main branch .

Said Dr . Ferenc : “ Doctors working in the catheter lab should now consider this approach if they have patients with suitable anatomy for both techniques . Cardiologists can use culotte stenting with more confidence , knowing that this technique is associated with a very low angiographic restenosis rate and lower rate of TLR as compared with TAP stenting – even though it is slightly more challenging and requires appropriate training .” – European Heart Journal

DOCTORS : “ Modest ” Success with OCT In a trial comparing optical coherence tomography ( OCT ) -guided versus standard angiography-guided coronary intervention in ACS patients , the addition of OCT impacted directly on physician decisionmaking in half the cases and was associated with higher post-procedure blood flow .

“ This is the first randomized trial showing a potential positive effect on fractional flow reserve in ACS patients undergoing PCI and the higher the fractional flow reserve , the lower the event rate ,” according to Nicolas Meneveau , MD , PhD , University Hospital Jean Minjoz , Besançon , France .

The procedure – which involves introducing an imaging catheter into the coronary artery to identify plaque morphology , check vessel size ,

The SYNTAX Score is broadly used today for making decisions regarding the optimal revascularization strategy for a given patient . Now there is a SYNTAX 2 ( and a SYNTAX 3 is around the corner ). CSWN : I talked with Patrick Serruys , MD , PhD , a world renowned interventional cardiologist and currently professor of Cardiology in the Cardiovascular Science Division of the National Heart and Lung Institute ( NHLI ) of the Imperial College in London ( UK ). Use the QR code to access this video , taped at ESC . 16 .

lesion characteristics , and stent positioning and expansion – did significantly increase both procedural time and the use of contrast medium , but it did so without an increase in periprocedural complications or kidney injury .

The DOCTORS ( Does Optical Coherence Tomography Optimize Results of Stenting ) trial randomly assigned 240 patients with NSTEMI to either OCT-

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