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Background: Provisional stenting (PS) is the main treatment for a majority of coronary bifurcation lesion and includes PS with 1-stent and PS with 2-stent. However, the treatment difference between PS with 1-stent and with 2-stent remains unclear in patients with the acute coronary syndrome (ACS) and coronary bifurcation lesions., Materials and Methods: Overall, 820 ACS patients with Medina 1,1,1 or 0,1,1 coronary bifurcation lesion who had completed 3-year follow-up were included and assigned to the PS with 1-stent (n = 519) or the PS with 2-stent (n = 301) according to the use of final stenting technique. The primary endpoint was the target lesion failure (TLF) at 3 years since stenting procedures., Results: At 3-year follow-up, TLF occurred in 85 (16.4%) patients in the PS with 1-stent group and 69 (22.9%) in the PS with 2-stent group (hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.06-2.17, p = 0.021), mainly driven by a higher rate of target lesion revascularization (TLR) in the PS with 2-stent group (13.0% vs. 8.3%, HR 1.65, 95% CI 1.04-2.61, p = 0.033). Complex bifurcations, side branch (SB) pretreatment, intravascular imaging guidance, and hyperlipidemia were the four predictors for 3-year TLF. SB pretreatment was associated with increased 3-year TLR, leading to an extremely higher 3-year TLF., Conclusion: Provisional with 2-stent for patients with ACS is associated with a higher rate of 3-year TLF, mainly due to increased requirement of revascularization. SB pretreatment should be avoided for simple bifurcation lesion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sheiban, Ge, Kan, Zhang, Santoso, Munawar, Ye, Tian and Chen.)

Background: Reports showed no change of 7-day mortality after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) between 2001 and 2011 in China. National rolling one-year interventional standardized training programme began in September 2009. However, the improvement in clinical outcome following STEMI PCI after 2011 remains unclear., Methods and Results: This multicentre MOODY registry study aimed to analyse the clinical improvement after STEMI PCI. Of a total of 9265 acute MI patients registered from 24 centres, 3142 STEMIs having a first medical contact time ≤12 hours and undergoing primary PCI were assigned to the Pre Group (n = 1014, between March 1999 and October 2010) or the Post Group (n = 2128, between 2010 November and 2016 October). The primary endpoint was in-hospital cardiac death. Study endpoints were also compared between trained and untrained operators and between experienced (≥50 primary PCIs/year) and inexperienced personnel. In-hospital death after PCI was 3.0% in the Pre Group, significantly higher than 1.6% in the Post Group (P = .035). The improvements in clinical outcome after PCI between the 2016 and Pre Groups were stably sustained through one-year follow-up. The significant reduction for in-hospital death was noted when primary PCI was performed by trained (1.4% vs 5.4%, P < .001) or experienced (2.7% vs 4.8%, P = .001) operators, compared to untrained or inexperienced operators, respectively. Inclusion of the untrained operator into the conventional risk model strongly enhanced the prediction for endpoints. Age, Killip Class 3, diabetes, trans-radial approach and system delay were five predictors of in-hospital death after primary PCI., Conclusion: PCI for STEMI by a trained and experienced operator was associated with significant reduction of in-hospital death. Our results strongly warrant the need for promoting the current system response and patient education., (© 2020 Stichting European Society for Clinical Investigation Journal Foundation.)

Background: Differences in the predictors between ventricular septal rupture (VSR) and free wall rupture (FWR) have not been fully studied. Data on the prevalence and clinical outcome of heart rupture are limited., Hypothesis: This study aimed to investigate heart rupture incidence and clinical results in patients with acute myocardial infarction (AMI)., Methods: Of 9265 AMI patients in the MOODY registry between March 1999 and October 2016, a total of 146 were studied. The primary clinical endpoint was rupture prevalence and in-hospital mortality. Independent factors of heart rupture were analyzed using Cox proportional model and were compared between patients with VSR and those with FWR., Results: Of 9265 AMI patients, 146 (1.58%) patients had a heart rupture (FWR, 94 (1.02%)) and VSR (52 (0.56%)). All patients with FWR died during hospitalization, and in-hospital mortality was recorded in 37 (71.2%) patients with VSR, who had an extremely longer time delay from AMI onset to the first medical contact (FMC) (~20 h). FWR usually occurred in patients with ST-elevation myocardial infarction (STEMI) patients with a FMC ≥ 3 h, for whom primary reperfusion was not performed. Percutaneous repair at 1-2 weeks following AMI was associated with less mortality, and 9 of 38 patients who underwent non-primary reperfusion died post procedure., Conclusion: This study demonstrated the importance of shortening FMC to prevent VSR and of early primary reperfusion in STEMI patients to reduce FWR. Urgent closure of rupture is necessary to reduce in-hospital and 1-year mortality., Clinical Trial Registration: http://www.clinicaltrials.org, identifier: No. NCT03051048., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intravascular ultrasound (IVUS)-guided drug-eluting stent (DES) implantation is associated with fewer major adverse cardiovascular events compared with angiography guidance for patients with individual lesion subset. However, the beneficial effect on major adverse cardiovascular event outcome of IVUS guidance over angiography guidance in all-comers who undergo DES implantation still remains understudied., Objectives: This study aimed to determine the benefits of IVUS guidance over angiography guidance during DES implantation in all-comer patients., Methods: A total of 1,448 all-comer patients who required DES implantation were randomly assigned (1:1 ratio) to either an IVUS guidance or angiography guidance group. The primary endpoint was target-vessel failure (TVF) at 12 months, including cardiac death, target-vessel myocardial infarction, and clinically driven target-vessel revascularization (TVR). The procedure was defined as a success if all IVUS-defined optimal criteria were met., Results: At 12 months follow-up, 60 TVFs (4.2%) occurred, with 21 (2.9%) in the IVUS group and 39 (5.4%) in the angiography group (hazard ratio [HR]: 0.530; 95% confidence interval [CI]: 0.312 to 0.901; p = 0.019). In the IVUS group, TVF was recorded in 1.6% of patients with successful procedures, compared with 4.4% in patients who failed to achieve all optimal criteria (HR: 0.349; 95% CI: 0.135 to 0.898; p = 0.029). The significant reduction of clinically driven target-lesion revascularization or definite stent thrombosis (HR: 0.407; 95% CI: 0.188 to 0.880; p = 0.018) based on lesion-level analysis by IVUS guidance was not achieved when the patient-level analysis was performed., Conclusions: The present study demonstrates that IVUS-guided DES implantation significantly improved clinical outcome in all-comers, particularly for patients who had an IVUS-defined optimal procedure, compared with angiography guidance. (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in "All-Comers" Coronary Lesions [ULTIMATE]; NCT02215915)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The mechanism of miR-30a in myocardial fibrosis in rats with myocardial infarction (MI) was investigated. rAAV9-miR-30a was constructed and transfected to heart via injecting into the left ventricular cavity of MI rats. The sham operation group, control group, miR-30a group and miR-30a-NC group were established. Besides, the 3'-UTR of CTGF was inserted into luciferase expression plasmid (pMir-report), then transfected into COS1 cells. miR-30a and control miRNA were, respectively, cotransfected into COS1 cells. The expression of luciferase was detected before and after knockdown of the binding site of miR-30a and the 3'-UTR of CTGF. Four weeks after MI surgery, cardiac function was measured by color Doppler echocardiography, including short axis shortening (FS) and left ventricular ejection fraction (LVEF); the myocardial collagen volume fraction (CVF) was observed by Masson's staining; deposition of collagen I and collagen III were evaluated by immunohistochemical stain; using real-time PCR to detect expression levels of miR-30a and CTGF; the expression of CTGF was observed by western blotting. In MI group, cardiac function was significantly improved, while the expression levels of CVF, collagen I and III, the ratio of type I/III collagen, CTGF were significantly reduced. After knockdown the binding site of miR-30a and the 3'-UTR of CTGF, luciferase expression in COS1 cells decreased significantly. miR-30a might inhibit the expression of CTGF by directly combining with the 3'-UTR site of CTGF after MI, thereby reduce the production of collagen in myocardia, inhibit myocardial fibrosis, then improve cardiac function.

Background: Provisional stenting (PS) is the most common technique used to treat distal left main (LM) bifurcation lesions in patients with unprotected LM coronary artery disease undergoing percutaneous coronary intervention. The double kissing (DK) crush planned 2-stent technique has been shown to improve clinical outcomes in non-LM bifurcations compared with PS, and in LM bifurcations compared with culotte stenting, but has never been compared with PS in LM bifurcation lesions., Objectives: The authors sought to determine whether a planned DK crush 2-stent technique is superior to PS for patients with true distal LM bifurcation lesions., Methods: The authors randomized 482 patients from 26 centers in 5 countries with true distal LM bifurcation lesions (Medina 1,1,1 or 0,1,1) to PS (n = 242) or DK crush stenting (n = 240). The primary endpoint was the 1-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Routine 13-month angiographic follow-up was scheduled after ascertainment of the primary endpoint., Results: TLF within 1 year occurred in 26 patients (10.7%) assigned to PS, and in 12 patients (5.0%) assigned to DK crush (hazard ratio: 0.42; 95% confidence interval: 0.21 to 0.85; p = 0.02). Compared with PS, DK crush also resulted in lower rates of target vessel myocardial infarction I (2.9% vs. 0.4%; p = 0.03) and definite or probable stent thrombosis (3.3% vs. 0.4%; p = 0.02). Clinically driven target lesion revascularization (7.9% vs. 3.8%; p = 0.06) and angiographic restenosis within the LM complex (14.6% vs. 7.1%; p = 0.10) also tended to be less frequent with DK crush compared with PS. There was no significant difference in cardiac death between the groups., Conclusions: In the present multicenter randomized trial, percutaneous coronary intervention of true distal LM bifurcation lesions using a planned DK crush 2-stent strategy resulted in a lower rate of TLF at 1 year than a PS strategy. (Double Kissing and Double Crush Versus Provisional T Stenting Technique for the Treatment of Unprotected Distal Left Main True Bifurcation Lesions: A Randomized, International, Multi-Center Clinical Trial [DKCRUSH-V]; ChiCTR-TRC-11001213)., (Copyright © 2017 American College of Cardiology Foundation. All rights reserved.)

Statins lower low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hsCRP), and the addition of ezetimibe to statins further reduces LDL-C and hsCRP. Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a potentially important pathogenic factor participating in the progression of atherosclerosis. The aim of current study was to investigate how the addition of ezetimibe to rosuvastatin treatment affects reductions in LDL-C, hsCRP and Lp-PLA2 in patients with acute myocardial infarction (AMI). A total of 135 patients were enrolled in the study within 24 h of AMI, and were randomized to receive 10 mg rosuvastatin or 10 mg rosuvastatin plus 10 mg ezetimibe daily. HsCRP, Lp-PLA2, total cholesterol (TC), triglycerides (TG), LDL-C and high-density lipoprotein cholesterol (HDL-C) were determined at baseline and after 1, 3, 6 and 12 months of treatment. The addition of ezetimibe to rosuvastatin led to greater reduction of LDL-C compared with rosuvastatin monotherapy (from 3.00 to 1.19 mmol/l vs. 2.93 to 1.49 mmol/l, respectively; P<0.05), as well as reduced levels of hsCRP (from 5.15 to 0.68 mg/l vs. 4.33 to 1.49 mg/l, respectively; P<0.05) and Lp-PLA2 (from 333.13 to 79.07 mg/l vs. 327.95 to 123.62 mg/l, respectively; P<0.05). A positive association was identified between reductions of Lp-PLA2 and the changes of LDL-C (r = 0.367; P=0.002). However, no significant correlation was observed between changes in Lp-PLA2 and hsCRP (r=0.264; P=0.512). The values of hsCRP and Lp-PLA2 appeared to increase during the first week after randomization, but dropped steeply to a lower level and remained stable thereafter. In conclusion, the addition of ezetimibe to rosuvastatin was demonstrated to further reduce LDL-C, hsCRP and Lp-PLA2 compared with rosuvastatin monotherapy in patients with AMI.

Objective: This study aimed to assess the long term outcomes (all-cause death, myocardial infarction, target vessel revascularization, and silent restenosis at 12 months) of one-stent vs. two-stent implantation due to coronary bifurcation lesionsin diabetic patients using AIR2 as a new endpoint., Methods and Results: A total of 178 diabetic patients with true coronary bifurcation lesions underwent percutaneous coronary intervention in the DK-Crush trials. All patients were stratified based on the stent placement strategy: one-stent group (n=76) and two-stent group (n=102). Results showed the primary endpoint, AIR2, in one-stent group was twice that in two-stent group (32.9% vs. 16.7%, P=0.013). The incidence of silent restenosis at 12 months was also significantly higher in one-stent group (19.7% versus 4.9%, P=0.003). Moreover, Kaplan-Meier analysis revealed the cumulative AIR2-free survival rate after a 12-month follow-up was markedly lower in one-stent group than in two-stent group. Interestingly, MACEs, including death, myocardial infarction and repeat revascularization, were not comparable between 2 groups (13.2% vs. 12.7%, P=0.935). Likewise, the incidence of definite or probable ST in one-stent group was also similar to that in two-stent group (2.6% vs. 4.9%, P=0.761)., Conclusion: Our study indicates that, in terms of the AIR2 as a combined clinical and angiographic endpoint, two-stent implantation is superior to one-stent implantation for the treatment of coronary bifurcation intervention in diabetic patients.

Background: Drug eluting stents (DESs) made with biodegradable polymer have been developed in an attempt to improve clinical outcomes. However, the impact of biodegradable polymers on clinical events and stent thrombosis (ST) remains controversial., Methods: We searched Medline, the Cochrane Library and other internet sources, without language or date restrictions for articles comparing clinical outcomes between biodegradable polymer DES and durable polymer DES. Safety endpoints were ST (definite, definite/probable), mortality, and myocardial infarction (MI). Efficacy endpoints were major adverse cardiac event (MACE) and target lesion revascularization (TLR)., Results: We identified 15 randomized controlled trials (n = 17 068) with a weighted mean follow-up of 20.6 months. There was no statistical difference in the incidence of definite/probable ST between durable polymer- and biodegradable polymer- DES; relative risk (RR) 0.83; 95% confidence interval (CI) 0.62-1.11; P = 0.22. Biodegradable polymer DES had similar rates of definite ST (RR 0.94, 95% CI 0.66-1.33, P = 0.72), mortality (RR 0.94, 95% CI 0.82-1.09, P = 0.43), MI (RR 1.08, 95% CI 0.92-1.26. P = 0.35), MACE (RR 0.99, 95% CI 0.91-1.09, P = 0.85), and TLR (RR, 0.94, 95% CI 0.83-1.06, P = 0.30) compared with durable polymer DES. Based on the stratified analysis of the included trials, the treatment effect on definite ST was different at different follow-up times: ≤ 1 year favoring durable polymer DES and >1 year favoring biodegradable polymer DES., Conclusions: Biodegradable polymer DES has similar safety and efficacy for treating patients with coronary artery disease compared with durable polymer DES. Further data with longer term follow-up are warranted to confirm the potential benefits of biodegradable polymer DES.

Objective: To investigate the effect of low shear stress (LSS) on apoptosis of human vascular endothelial cells (ECs) and explore the possible mechanisms., Methods: Parallel flow chamber was used to apply LSS at 2 dyne/cm(2) on EA.hy926 cells derived from human umbilical vein endothelial cells for 120 min. Cell apoptosis following LSS was verified by morphological observation, DAPI staining and TUNEL test. The level of intracellular reactive oxygen species (ROS) was measured by dihydroethidium (DHE) and mitoSOX. Western blotting was performed to detect the activity of Akt in the cells., Results: EC detachment and apoptosis were observed after exposure to 2 dyne/cm(2) LSS for 120 min. Time course study showed that the phosphorylation level of Akt on residues Ser473 and Thr308 was elevated after flow initiation. Exposure to LSS at 2 dyne/cm(2) for 120 min resulted in increased ROS production in the ECs at both the mitochondrial and cytoplasmic levels., Conclusion: Akt activation and increased ROS levels are involved in LSS-induced EC apoptosis.

Aims: The impact of intravascular ultrasound (IVUS) guided coronary drug-eluting stent (DES) implantation on clinical outcomes remains controversial. A meta-analysis of the currently available clinical trials investigating IVUS-guided DES implantation was undertaken., Methods and Results: We searched Medline, the Cochrane Library and other internet sources, without language or date restrictions, for published articles comparing clinical outcomes between IVUS-guided and angiography-guided DES implantation. Clinical studies with both adjusted and unadjusted data were included. Eleven studies were identified (one randomised controlled trial and 10 registries) and included in the meta-analysis with a weighted follow-up time of 20.7±11.5 months. Compared with angiography guidance, IVUS-guided DES implantation was associated with a reduced incidence of death (hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.48-0.73, p<0.001), major adverse cardiac events (HR: 0.87, 95% CI: 0.78-0.96, p=0.008) and stent thrombosis (HR: 0.58, 95% CI: 0.44-0.77, p<0.001). The incidence of myocardial infarction (HR: 0.82, 95% CI: 0.63-1.06, p=0.126), target lesion (HR: 0.90, 95% CI: 0.73-1.11, p=0.316) and target vessel (HR: 0.90, 95% CI: 0.77-1.05, p=0.195) revascularisation was comparable between the angiography and IVUS-guided arms. A repeat meta-analysis of propensity-matched studies only (six studies, n=5,300) yielded broadly similar results in terms of clinical outcomes., Conclusions: IVUS-guided coronary DES implantation is associated with a significant reduction in death, MACE and stent thrombosis compared to angiography guidance. Appropriately powered randomised trials are necessary to confirm the findings from this meta-analysis.

Aims: The present study aimed to compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions., Methods and Results: Between March 2004 and April 2007, 633 consecutive patients with ULMCA bifurcation lesions (232 in the one-stent group and 401 in the two-stent group) were prospectively enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularisation (TVR), at five-year follow-up. Patients in the the two-stent group were classified as DK crush (n=155) and other two-stent techniques (culotte, T-stenting, kissing stenting and classical crush, n=246). Forty-seven (16.8%) patients in the one-stent group crossed over to the two-stent group. The one-stent group was associated with an increased incidence of MI compared to the two-stent approach (10.5% vs. 5.5%, p=0.025). The crude rate of MACE at five years was 28.0% in the one-stent group and 28.4% in the two-stent group (p=0.927). DK crush was associated with a significantly decreased five-year MACE compared to the other two-stent approaches or the one-stent approach (DK crush: 14.8% vs. other two-stent approaches: 37.0%, one-stent approach: 28.0%, p<0.001). The main benefit of DK crush primarily appeared to be secondary to a reduction in TVR (7.7% vs. 30.5% vs. 18.1%, p<0.001). By Cox regression analyses, the non-DK crush two-stent technique, a high SYNTAX Score (≥33) or New Risk Stratification (NERS) score (>20), and incomplete revascularisation were shown to be independent predictors of MACE at five-year follow-up., Conclusions: With distal left main true bifurcations, the two-stent technique (excluding DK crush) is an independent predictor of long-term MACE. DK crush is associated with more favourable long-term clinical outcomes. Confirmation of these findings is required from randomised controlled trials.

Two hundred forty-six patients with 252 bifurcation lesions were enrolled into a prospective, nonrandomized study to use paclitaxel-eluting or sirolimus-eluting stent for crush stenting in the treatment of coronary bifurcation lesions. Compared with the sirolimus-eluting stent group, the paclitaxel-eluting stent group had significantly higher mean late lumen and binary angiographic restenosis rates. Sirolimus-eluting stent versus paclitaxel-eluting stent recipients had significantly lower in-segment restenosis in the entire main vessel (15.7% vs 3.1%, P = .004), and simultaneous side branch and main vessel restenoses were solely detected in the paclitaxel-eluting stent group (11.9% vs 0%, P = .03). Target-lesion vessel revascularization and cumulative major adverse cardiac events rates were significantly higher in the paclitaxel-eluting versus the sirolimus-eluting stent group (17.99% vs 8.41%, P = .01; 19.4 vs 9.3%, P = .01; 23.6 vs 11.2%, P = .03). In this study with crush stenting, use of sirolimus-eluting stent, compared with paclitaxel-eluting stent, yielded significantly lower late lumen loss, restenosis, and revascularization rates, with comparable safety by 8-month follow-up.

Background: Studies have revealed that stem cells improve clinical outcomes in patients with severe ischemic cardiomyopathy, but the role of bone marrow mesenchymal stem cells is not well understood., Methods: Twenty-two patients received an implantation of autologous bone marrow mesenchymal stem cell therapy; another 23 patients were placed in a control group after percutaneous coronary intervention (PCI) of the chronically occluded left anterior descending artery., Results: Reversible defect in the cell therapy group decreased from 16 +/- 8% at baseline to 6 +/- 2% at 12 months (p < 0.05), and this improvement was maintained throughout the entire follow-up period. Compared to the control group (5 +/- 3 METS at baseline vs. 5 +/- 3 METS at 3 months; p = NS), the level of exercise tolerance improved significantly 3 months after cell therapy (5 +/- 2 METS at baseline vs. 7 +/- 3 METS at 3 months; p < 0.05). The NYHA function class also improved in the cell therapy group (2.7 +/- 0.8 at baseline vs. 1.6 +/- 0.1 at 3 months; p < 0.05). PCI alone did not increase left ventricular ejection fraction (LVEF), but following stem cell therapy, the LVEF increased significantly from 26 +/- 6% at baseline to 37 +/- 9% at 3 months (p < 0.05)., Conclusion: Intracoronary transplantation of autologous bone marrow mesenchymal stem cells improved clinical outcomes in patients with chronic ischemic cardiomyopathy.

Objective: This is a prospective study to evaluate the clinical outcomes of endovascular repair in patients with different phases of type B aortic dissection., Background: Endovascular repairing with stent-grafts is an innovative technique for type B acute aortic dissection. There is no previous study regarding outcomes in different time phases., Methods: Sixty-two patients underwent endovascular stent-grafts. There were 23 in the early phase (<24 hr), 20 in the late phase (>or=24 hr to 2 weeks), and 19 in the chronic phase (>2 weeks)., Results: The early phase group had the lowest ratio of stent-grafts to patient and the shortest stent-graft length. The chronic phase group had the largest diameter of false lumen. The technical success rate was 100%; no patient died within hospital. Three patients died within 30 days, with the same death rate in every group. Compared with acute patients, the chronic group had a higher volume of contrast, a higher creatinine post-procedure, and a higher incidence of contrast-induced nephropathy. Multiple regression analysis demonstrated that creatinine and endoleak were independent factors in predicting late death (95% CI, 3.4-26%, P < 0.01). The overall cardiovascular event-free survival was 88.9% +/- 2.1% at 30 days, 87.2% +/- 4.1% at 1 year, and 81.4% +/- 6.3% at 2 years. CT angiography identified the complete or partial thrombosis of the false lumen to be 95.7%., Conclusions: Endovascular repairing with stent-graft is safe, feasible, and able to treat type B aortic dissection in all phases. However, chronic renal dysfunction was an independent factor which contributed to a lower survival rate of chronic phase patients.