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Left Main Bifurcation Stenting: Impact of Ischemia on CV Mortality
Quick Takes
- Patients with residual ischemia had a significantly higher risk of 3-year CV death and bifurcation-oriented composite endpoint compared with no residual ischemia.
- Integration of functionally significant residual ischemia assessed by post-PCI quantitative flow ratio into the model with clinical factors showed significantly increased discrimination and reclassification ability for CV death.
- These data suggest an interventional algorithm, incorporating the strategy of routine post-PCI physiology-based assessment when treating LM bifurcation even when PCI appears anatomically satisfactory, may improve clinical outcomes.
Study Questions:
What is the rate and what are the prognostic implications of post-procedural physiologically significant residual ischemia according to Murray law-based quantitative flow ratio (μQFR) after left main (LM) bifurcation percutaneous coronary intervention (PCI)?
Methods:
The investigators included consecutive patients undergoing LM bifurcation stenting at a large tertiary care center between January 2014 and December 2016 with available post-PCI μQFR. Physiologically significant residual ischemia was defined by post-PCI μQFR values ≤0.80 in the left anterior descending (LAD) or left circumflex artery (LCX). The primary outcome was 3-year cardiovascular (CV) death. The major secondary outcome was 3-year bifurcation-oriented composite endpoint (BOCE). The cumulative incidence of clinical events was presented as Kaplan–Meier estimates. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Multivariable Cox regression analysis with incorporation of covariates was performed to adjust possible confounders.
Results:
Among 1,170 included patients with analyzable post-PCI μQFR, 155 (13.2%) had residual ischemia in either LAD or LCX. Patients with versus those without residual ischemia had a higher risk of 3-year CV mortality (5.4% vs. 1.3%; adjusted HR, 3.20; 95% CI, 1.16-8.80). The 3-year risk of BOCE was significantly higher in the residual ischemia group (17.8% vs. 5.8%; adjusted HR, 2.79; 95% CI, 1.68-4.64), driven by higher incidence of the composite of CV death and target bifurcation-related myocardial infarction (14.0% vs. 3.3%; adjusted HR, 4.06; 95% CI, 2.22-7.42). A significant, inverse association was observed between continuous post-PCI μQFR and the risk of clinical outcomes (per 0.1 μQFR decrease, HR of CV death, 1.27; 95% CI, 1.00-1.62; HR of BOCE, 1.29; 95% CI, 1.14-1.47).
Conclusions:
The authors report that after angiographically successful LM bifurcation PCI, residual ischemia assessed by μQFR was associated with a higher risk of 3-year CV death, indicating the superior prognostic value of post-PCI physiological assessment.
Perspective:
This post hoc analysis from a single-center prospective cohort study reports that patients with residual ischemia had significantly higher risk of 3-year CV death and BOCE, compared with no residual ischemia. Furthermore, integration of functionally significant residual ischemia assessed by post-PCI μQFR into the model with clinical factors showed significantly increased discrimination and reclassification ability for CV death. These data suggest an interventional algorithm, incorporating the strategy of routine post-PCI physiology-based assessment when treating LM bifurcation even when PCI appears anatomically satisfactory, may improve clinical outcomes. However, given significant limitations of the current analysis, additional prospective validation is indicated.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention
Keywords: Myocardial Ischemia, Percutaneous Coronary Intervention
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