Defini&on  Study:  Defining  simple  and  complex  coronary  bifurca&on  lesions  

Shao-­‐Liang  Chen,  MD,  FACC  Nanjing  First  Hospital,  Nanjing  

Medical  University,  Nanjing,  China  

Background  (1):Anatomic  difference

Better one because--- 1. easily to be numerized 2. easily to remember 3. simple classification

Best?----NO lack of lesions features lesion length RVD angle calcification/tortuousi

Medina 1,1,1

Medina 1,1,1

Medina 1,1,1

SB/M-DS + SB/MV- lesion length are different

Bifurcation angle is different

Multiple-bifurcation lesions

LAD-D1(1,1,1) --Tortuous LAD --Calcified LAD --SB long lesion ---larger SB LAD-LCX (0,1,1)

DKCRUSH-1 DKCRUSH-II DKCRUSH-III Lesion types 111/011/10

1 111/0111 111/011

Techniques DES

DK/crush PES

DK/provisional SES

DK/culotte SES

Locations all all LMd SB diameter lesion length

2.0 mm 10.2 mm

>2.5 mm 11.3 mm

LCX 16.9 mm

AMI<2-week √ √ √ CTO √ √ √ No. patients 312 370 420

1st Endpoint MACE 8-m MACE 12-m MACE 12-m Chen. et al, JECI, JACC, JACC

Background  (2):  Difference  in  data

first study repoted the difference in TLR Why?--lesions complexity

A  risk  stra&fica&on  for  guiding  sten&ng  technique  Is  urgently  required

Definition Study design

Inclusion criteria: SB diameter≥2.5 mm Medina 1,1,1 or 0,1,1 Prospective registry Multi-center

Chen et al, JACC interv 2014， online

Chen et al. JACC interv 2014 in press

MACE as state, variables if Major:p<0.001 Minor:0.01>p ≥ 0.001 Were included; Variables if p≥0.01 Were excluded

P Sen

(%) Spe

(%)

Severe angulation in SB

0.039 44 45

Previous PCI 0.035 48 57

Diabetes 0.038 62 49

MV RVD<2.5 mm 0.019 66 43

Variables excluded from Training group

Chen et al. JACC interv 2014， online

Training group: major criteria

P Sen

(%) Spe

(%)

Major 1:    LMd bif, SB-DS≥70% SB lesion ≥ 10mm

<0.001

78 71

Major 2:

non-­‐LMd  bif:                                                SB-DS≥90%,

SB lesion ≥ 10mm

<0.001 78 72

Chen et al. JACC interv 2014，online

Training group: minor criteria

P Sen

(%) Spe

(%) 1: ≥Moderator calci 0.002 64 65

2: Multiple Bif. 0.007 68 60

3: Thrombus-containing 0.002 66 64

4: MV lesion ≥ 25 mm 0.010 57 66

Chen et al. JACC interv 2014, online

Definition of complex Bif Sen

(%) Spe

(%)

One  Major+any two of Minor    criteria  

>84  (78)

≥79  (71-­‐72)

Chen et al. JACC interv 2014, online

ROC curve: 1 major+ any 2 minor

Chen et al. JACC interv 2014，on;ine

Benching point

Chen et al. JACC interv 2014, online

This new stratification was tested in Study group

Simple (n=2553,69%)

Complex (n=1107,31%)

Age (yr.) 65±10 68±9 Male, n (%) 1911(74.9) 873(78.0) Diabetes, n (%) 876(34.3) 498(45.0) AMI, n (%) 237(9.3) 135(12.2) CHF, n (%) 411(16.1) 246(22.2) LVEF<40% 144(5.6) 199(17.9) Current smoker, n(%) 318(12.5) 75(6.8) Platelet, x 109/L 185.7±66.54 202.82±70.14 Creatinine, mmol/L 85.41±48.11 89.92±49.8 Hs-CRP, mg/dl 2.67±0.59 2.75±0.68

Clinical variables

Chen et al. JACC interv 2014, online

Simple vs. Complex: 1-year MACE

Provisional  vs  complex  sten&ng  for  overall  pa&ents

Chen et al. JACC interv 2014 on;ine

Provisional  vs  complex  sten&ng  for  simple  bif.  Lesions:  TLR

In  line  with  DKCRUSH-­‐II  finding

Chen et al. JACC interv 2014 online

Provisional  vs  complex  sten&ng  for  complex  bif.:    in-­‐hos.  MACE

Chen et al. JACC interv 2014 online

Provisional  vs  complex  sten&ng  for  complex  bif.  Lesions:  death  rate

Conclusion •  Complex bifurcation lesions had higher rates of one-year MACE and ST.  

•  PS for complex lesions elicited more cases of cardiac death and MACE.  

•  For  Simple bif.,  provisional T is  good  enough  •   For  complex  bif.,  carefully  selec&on  of  2-­‐stent  is  indicated  

•  RCT relying on this new classification is required

Chen et al. JACC interv 2014 online

Thanks  for  your  aWen&on!