Epidemiology and clinical impact of different anatomical phenotypes of the left main coronary artery.

Several studies have produced estimates of the outcome of percutaneous coronary intervention (PCI) in the field of left main (LM) coronary artery disease, but no research has been found that surveyed the issue of a comprehensive knowledge of LM anatomy and assessed the impact of different anatomic phenotypes on the likelihood of developing complications after LM PCI. We sought to develop a specific investigation on the basis of the regional anatomy and quantitative analysis of a large series of angiograms performed in our institution. We reviewed the baseline selective digital coronary angiographic examinations of 1,000 patients who did not undergo LM PCI and 296 patients with significant LM stenosis who did undergo PCI. All patients in both groups underwent a comprehensive qualitative and quantitative assessment of LM anatomical features according to several parameters. Hierarchical cluster analysis (HCA) was used to identify different anatomic phenotypes of the LM coronary artery. Three different anatomical patterns were identified by HCA. The proportion of patients with LM disease increased across clusters (19% in cluster 1, 27% in cluster 2 and 44% in cluster 3, p < 0.001). No differences were observed in terms of 18-month major adverse cardiac event-free survival among patients with LM disease undergoing PCI stratified by clusters (log rank p = 0.77). In conclusion, LM phenotypes can be identified that are more likely to present with atherosclerotic disease and significant stenosis.

A novel 3-d reconstruction system for the assessment of bifurcation lesions treated by the mini-crush technique.

BACKGROUND: Conventional two-dimensional angiography lacks the ability to properly image the true bifurcation geometry, and its percutaneous coronary intervention-induced changes in the clinical setting. METHODS AND RESULTS: A novel three-dimensional reconstruction system was investigated by retrospectively analyzing 39 lesions in 35 consecutive patients with coronary bifurcation disease treated with the mini-crush technique. At baseline, significant correlations were proved between two- and three-dimensional systems in terms of either reference vessel diameter (R(2)= 0.68 and 0.29 for main and side branches, respectively), minimum lumen diameter (R(2)= 0.73 and 0.36), stenosis diameter (R(2)= 0.69 and 0.29), and lesion length (R(2)= 0.48 and 0.58). These results were consistent with those observed after the procedure and at 8-month follow-up. Lesion length was significantly longer with the three-dimensional compared to the two-dimensional system for both main and side branches (P < 0.001, and P = 0.007, respectively). CONCLUSIONS: The three-dimensional quantitative reconstruction system may provide accurate evaluation of the complex curvilinear structure of bifurcation lesions when using a double stent technique.

The "mini-crush technique" for the treatment of coronary trifurcation lesions.

AIMS: Recent evidence suggest that coronary bifurcation lesions might be treated by DES using "the mini-crush technique" with low rate of MACE and restenosis both at main and side branches. However, the treatment of a coronary trifurcation lesion is more problematic. Here we assess the feasibility of the "mini-crush technique" for treating trifurcation lesions. METHODS AND RESULTS: We report on the treatment of trifurcation lesions using DES in all branches by the mini-crush technique in five consecutive patients (65+/-11.5 years) from December 2004 till March 2006. Independently, from the anatomical type of trifurcation, the mini-crush procedure was performed in all cases. After predilatation of all branches, positioning of stents in both side branches at a distance of 1-2 mm proximally to the carina of the trifurcation was performed. Side-branch stents were then deployed sequentially and crushed at the same time by a balloon positioned in the main branch. Afterwards, the main branch stent was advanced to cover the ostium of both side branches and deployed. The jailed wire technique was employed in all cases, and if possible in both branches. Final triple kissing balloon was employed in all cases. The "mini-crush technique" was performed safely in all the five patients obtaining an excellent angiographic result at 8.0+/-1.0 months follow-up angiography. CONCLUSIONS: The "mini-crush technique" with DES can be safely performed giving complete coverage of the ostium of side branches and optimising side branch access.

Early discharge in acute myocardial infarction after clinical and angiographic risk assessment.

BACKGROUND: Acute myocardial infarction (AMI) management aims to ensure the best care for patients while reducing hospital stay. The aim of this study was to evaluate feasibility and safety of early discharge (defined as discharge between 48 and 72 h from AMI) in low-risk patients after uncomplicated infarction. METHODS: We prospectively evaluated 321 patients (age: 59 +/- 11.7), who were admitted for AMI between February 2004 and August 2005 and assigned to 'low'-risk and 'high'-risk groups according to clinical and angiographic criteria. Low-risk patients were discharged between 48 and 72 h from admission. After discharge, all patients were re-evaluated after 1 week, 6 weeks and 6 months for AMI. We also retrospectively considered a control group of 68 low-risk patients with AMI admitted to our Coronary Intensive Care Unit (CICU) in the previous 4 months before the beginning of the study with standard discharge after at least 7 days of hospital stay. RESULTS: No events were detected in the first week after discharge. In low-risk patients, the cumulative major adverse event rate was 0.6% after 6 weeks, whereas in high-risk patients, the rate was 9% (P < or = 0.01). After 6 months, in the low-risk group, the cumulative major adverse event rate was 2%, whereas in the high-risk group, it was 10% (P < or = 0.01). The control group showed a cumulative major adverse event rate of 1.5% after 6 months, with no statistically significant difference between controls and low-risk patients. The type of AMI did not influence risk assessment and clinical outcome. CONCLUSION: Our data support the short-term safety and cost-effectiveness of early discharge in patients with uncomplicated AMI, treated with successful percutaneous coronary intervention.