Strategies for drug-eluting stent treatment of bifurcation coronary artery disease in the United States: insights from the e-Cypher S.T.L.L.R.trial.

OBJECTIVES: Our goal is to report the first large multicenter data for percutaneous coronary intervention (PCI) of bifurcation disease with drug-eluting stents (DES) in the United States. BACKGROUND: Bifurcation PCI remains a challenge to this date. There are limited data on outcomes of patients treated with bifurcation DES implantation, particularly in the United States. METHODS: There were 161 patients with bifurcation disease [side branch (SB) >or=2-mm] treated with >or=1 sirolimus-eluting stents at 41 centers participating in the Stent deployment Techniques on cLinicaL outcomes of patients treated with the cypheRstent (STLLR) trial. There was no protocol mandated strategy for bifurcation PCI. One-year outcome data were collected. Angiographic and clinical data were adjudicated independently. RESULTS: There were 147 patients (91.3%) treated with single stent strategy. Only 14 (8.7%) patients received sirolimus-eluting stents implantation in both branches. Among patients with single stent strategy, double wire strategy (DW) was selected in 27 (18.4%) patients whereas single wire strategy (SW) was selected in 120 (81.6%) patients. There were 48 (32.7%) Medina 1,1,1 bifurcations treated with SW (n = 34; 70.8%) and DW (n = 14; 29.2%). There were 26 procedures started with SW which had SB dilatation during the procedure, one as a bailout (TIMI-1 grade flow in the SB). Overall 1-year death, myocardial infarction, and target lesion revascularization occurred in 2.4, 4.0, and 5.6%, respectively. There was no significant difference in clinical outcomes between SW and DW. SB dilatation was associated with a high rate of stent thrombosis (8.6%). CONCLUSIONS: Main branch stenting without SB protection is the most common approach utilized in the STLLR study, which may reflect contemporary DES bifurcation strategies in the Unite States. This strategy was associated with an acceptable low incidence of adverse outcomes at 1-year.

Two-dimensional and Doppler transesophageal echocardiographic delineation and flow characterization of anomalous coronary arteries in adults.

OBJECTIVES: The purpose of this study was to examine the use of transesophageal echocardiography (TEE) in the identification and flow characterization of congenital coronary anomalies. BACKGROUND: Congenital coronary anomalies in adults are rare but may cause serious cardiac complications. The use of TEE in evaluation of this entity has not been well defined. Very little is known regarding flow patterns in anomalous coronaries assessed by Doppler TEE. METHODS: A total of 32 consecutive adult patients were studied using TEE to define the origin, course, and proximal flow pattern of suspected coronary anomalies. RESULTS: Coronary anomalies identified using TEE included anomalous origin from the pulmonary trunk (n = 2), right sinus (n = 18), left sinus (n = 9), single coronary (n = 2), and left main coronary fistula (n = 1). Multiplane TEE performed in 20 cases simplified the delineation of more complex coronary anomalies. The origin was identified in all patients, proximal course delineated in 31, and proximal flow pattern characterized by pulsed Doppler in 23 of 32 patients. In 16 anomalous left main, left anterior descending, or left circumflex coronary arteries, an abnormal systolic flow pattern (ie, systolic/diastolic time-velocity integral ratio >1) occurred exclusively (P <.001) when the anomalous artery had an intermediate (100%; 5/5) versus anterior or posterior course (0%; 0/11) relative to the aortic and pulmonary artery trunks. A systolic flow pattern was also evident in 4 (80%) of 5 patients with an anomalous right coronary artery with an intermediate course. CONCLUSIONS: TEE, particularly with a multiplane probe, has an important complementary role to coronary angiography in delineating the proximal course and pattern of flow in anomalous coronaries. Predominant systolic flow pattern in anatomically left proximal anomalous coronaries signifies an intermediate course between the aorta and the pulmonary trunk and may be clinically useful for risk stratification.