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Original article
DOI: 10.1016/j.rec.2020.06.011
Available online 18 July 2020
Optimal strategy for side branch treatment in patients with left main coronary bifurcation lesions
Estrategia óptima para el tratamiento de lesiones en bifurcación del tronco coronario izquierdo
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Jihoon Kima, Joo Myung Leea, Taek Kyu Parka, Jeong Hoon Yanga, Joo-Yong Hahna, Jin-Ho Choia, Seung-Hyuk Choia, Ki Bae Seungb, Seung-Ho Hurc, Seung-Woon Rhad, June-Hong Kime, Rak Kyeong Choif, Ju Hyeon Ohg, Hyo-Soo Kimh, Seung-Hwan Leei, Jong-Seon Parkj, Sung Yun Leek, Dong Woon Jeonl, Myung Ho Jeongm, Jae-Hwan Leen, Sang Yeub Leeo, Woo-Jung Parkp, Young Bin Songa,
Corresponding author
youngbin.song@gmail.com

Corresponding author: Heart Vascular Stroke Institute, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea.
, Hyeon-Cheol Gwona
a Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
b Division of Cardiology, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
c Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
d Division of Cardiology, Korea University Guro Hospital, Seoul, Republic of Korea
e Division of Cardiology, Pusan National University Yangsan Hospital, Pusan, Republic of Korea
f Division of Cardiology, Mediplex Sejong Hospital, Incheon, Republic of Korea
g Division of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
h Division of Cardiology, Seoul National University Hospital, Seoul, Republic of Korea
i Division of Cardiology, Yonsei University Wonju Christian Hospital, Wonju, Republic of Korea
j Division of Cardiology, Yeungnam University Medical Center, Daegu, Republic of Korea
k Division of Cardiology, Inje University Ilsan Paik Hospital, Ilsan, Republic of Korea
l Division of Cardiology, National Health Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
m Division of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
n Division of Cardiology, Chungnam National University Hospital, Daejeon, Republic of Korea
o Division of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
p Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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Table 1. Baseline clinical characteristics
Table 2. Procedural characteristics
Table 3. Procedural outcomes
Table 4. Clinical outcomes at 1 year
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Additional material (1)
Abstract
Introduction and objectives

There are no guidelines regarding the most appropriate approach for provisional side branch (SB) intervention in left main (LM) bifurcation lesions.

Methods

The present prospective, randomized, open-label, multicenter trial compared conservative vs aggressive strategies for provisional SB intervention during LM bifurcation treatment. Although the trial was designed to enroll 700 patients, it was prematurely terminated due to slow enrollment. For 160 non-true bifurcation lesions, a 1-stent technique without kissing balloon inflation was applied in the conservative strategy, whereas a 1-stent technique with mandatory kissing balloon inflation was applied in the aggressive strategy. For 46 true bifurcation lesions, a stepwise approach was applied in the conservative strategy (after main vessel stenting, SB ballooning when residual stenosis> 75%; then, SB stenting if residual stenosis> 50% or there was a dissection). An elective 2-stent technique was applied in the aggressive strategy. The primary outcome was a 1-year target lesion failure (TLF) composite of cardiac death, myocardial infarction, or target lesion revascularization.

Results

Among non-true bifurcation lesions, the conservative strategy group used a smaller amount of contrast dye than the aggressive strategy group. There were no significant differences in 1-year TLF between the 2 strategies among non-true bifurcation lesions (6.5% vs 4.9%; HR, 1.31; 95%CI, 0.35-4.88; P=.687) and true bifurcation lesions (17.6% vs 21.7%; HR, 0.76; 95%CI, 0.20-2.83; P=.683).

Conclusions

In patients with a LM bifurcation lesion, conservative and aggressive strategies for a provisional SB approach have similar 1-year TLF rates.

Keywords:
Left main disease
Side branch
Percutaneous coronary intervention
Outcomes
Abbreviations:
FKB
LM
MV
PCI
SB
TLF
Resumen
Introducción y objetivos

No hay directrices sobre el tratamiento óptimo de la rama secundaria (RS) en lesiones en bifurcación del tronco coronario izquierdo (TCI).

Métodos

Ensayo clínico aleatorizado, multicéntrico y abierto que comparó una estrategia conservadora frente a una agresiva para el abordaje de la RS durante la intervención percutánea en lesiones bifurcadas del TCI. Aunque se diseñó para incluir a 700 pacientes, se terminó prematuramente debido a la baja tasa de reclutamiento. Se trataron 160 lesiones en bifurcación no verdaderas mediante implante de 1 stent sin inflado simultáneo de balones (técnica conservadora) o con la técnica de 1 stent con inflado simultáneo de balones obligatorio (estrategia agresiva). En 46 bifurcaciones verdaderas del TCI, se realizó un abordaje escalonado con estrategia conservadora (colocación del stent en el vaso principal y dilatación con balón de la RS si la estenosis residual era> 75%, y después implante de stent en la RS si la estenosis residual era> 50% o disección). El tratamiento electivo de 2 stents se usó como estrategia agresiva. El objetivo primario de fallo en la lesión diana fue el compuesto de muerte cardiaca, infarto de miocardio o revascularización de la lesión diana.

Resultados

Entre las bifurcaciones no verdaderas, en el grupo tratado mediante estrategia conservadora, se utilizó una cantidad de contraste significativamente menor que con la estrategia agresiva. No hubo diferencias en el objetivo primario al año entre las 2 estrategias en las lesiones en bifurcación no verdaderas (el 6,5 frente al 4,9%; HRa=1,31; IC95%, 0,35-4,88; p=0,687) y las bifurcaciones verdaderas (el 17,6 frente al 21,7%; HRa=0,76; IC95%, 0,20-2,83; p=0,683).

Conclusiones

En pacientes con lesiones del TCI en bifurcación, la estrategia conservadora en el tratamiento provisional de la RS tuvo un riesgo de fallo en la lesión diana al año similar al de una estrategia agresiva.

Palabras clave:
Enfermedad del tronco coronario izquierdo
Rama secundaria
Intervención coronaria percutánea
Resultados

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